Every finding on record at White Blossom Care Center

Based on interview and record review, the facility failed to ensure an appropriate and safe discharge process for one of three residents (Resident 1) when:1. Failure to provide the Notice of Proposed Transfer/Discharge as soon as practicable before the discharge;2. Failure to assess and identify Resident 1's living situation; and3. Failure to coordinate and confirm home health services.These failures resulted in Resident 1 being discharged without a confirmed discharge destination and follow-up services, placing the resident at risk for unmet medical needs, interruption in care, and harm. Resident 1 was found on 4/2/26, 13 days after discharge from the facility, in a fast food place with left facial droop (uneven appearance of the face), slurred speech (slow speech or mumbling), left upper and lower extremity (a limb of the body, e.g., arm or leg) weakness and was brought to the emergency department by ambulance. Findings:Review of Resident 1's undated admission Record indicated the resident was admitted to the facility on [DATE] with a diagnoses including benign neoplasm of cerebral meninges (a non-cancerous growth on the protective lining that surrounds the brain), other specified disorders of the brain (any condition that affects how the brain works), muscle weakness generalized (loss of strength in the muscles that results in inability to do specific tasks), acute pulmonary insufficiency following thoracic surgery (a complication that caused breathing issue), type II diabetes mellitus (high levels of sugar in the blood). Resident 1 was discharged from the facility on 3/20/26.Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/5/26, indicated a BIMS (Brief Interview for Mental Status, tool used to screen memory and thinking skills, score range 0-15) score of 15 (Resident 1's thinking skills are normal).Review of Resident 1's MDS Functional Abilities (assessment on how much help a resident need to perform daily life activities), dated 3/5/26, indicated Resident 1 required supervision or touching assistance (steadying and/or touching assistance) to partial/moderate assistance (lift, holds, or support trunk or limbs) to complete self-care and mobility activities.Review of Resident 1's Discharge Summary from an acute care hospital, dated 3/3/26, indicated an admission diagnosis of brain mass (a growth in the brain) and status post left pterional craniotomy (a surgical procedure that removes a piece of the skull to access the brain) for tumor resection on 2/19/26.Review of Resident 1's Resident Centered Social History and Discharge Planning Assessment, dated 3/6/26, indicated Post-discharge interventions were discussed and are expected to be needed to enhance safety and prevent readmission including assisted living facility options and home health options.Care planning intervention: coordinate home health and/or in-home support services.Review of Resident 1's Notice of Medicare Non-Coverage (NOMNC, an official document given to Medicare beneficiaries at least two days before their covered services are scheduled to end), dated 3/16/26, indicated Medicare coverage for skilled nursing care services will end on 3/20/26 and discharge date will be on 3/21/26. Resident 1 signed the notice that indicated she was notified that coverage of the services will end on the date on the notice.Review of Resident 1's Social Service Note, dated 3/16/26, indicated, Resident stated that due to transportation arrangement issue, resident would like to do a patient-driven discharge on 3/20 instead.Review of Resident 1's Notice of Proposed Transfer/Discharge (a mandatory written document used in skilled nursing facilities to notify residents of an upcoming transfer or discharge, usually 30 days in advance), indicated effective date of transfer/discharge: [DATE]. Resident 1 signed the Notice of Proposed Transfer/discharge on [DATE] that indicated she received a written copy of the notice.Review of Resident 1's Discharge Summary and Post-Care Instructions, dated 3/20/26, did not indicate the discharge location address and home health services agency name and contact information.During an interview with the Director of Social Services (DSS), on 4/15/26 at 12:40 p.m., the DSS stated that Resident 1 was given the NOMNC on 3/16/26 and was informed that the discharge date was 3/21/26. The DSS also stated that Resident 1 wanted to be discharged on 3/20/26. The DSS further stated that home health services including physical therapy, occupational therapy, and nursing were set up. The DSS also stated Resident 1 was safe to be discharged home.During a concurrent interview and record review with the DSS, on 4/15/26 at 3 p.m., the DSS confirmed that the Discharge Summary and Post-Care instructions given to Resident 1 on 3/20/26 did not have the discharge location address and home health services agency name and contact information.During an interview with the DSS, on 4/17/26 at 11:54 a.m., the DSS stated that Resident 1 did not specifically say that she wanted to go home. The DSS also stated that Resident 1 was still trying to figure out her home situation because Resident 1's family member (FM) A was in Los Angeles. The DSS further stated that Resident 1 was trying to figure out if FM B will be home when Resident 1 gets home.During a record review on 4/17/26 at 11:54 a.m., the DSS provided a copy of a note written on a home care agency note pad. It indicated [name] from [Home Health Agency] confirmed they received HH referral & auth *DC 3/20/26. [name] mentioned that they successfully spoke w/ [Resident 1] on the phone more than once. There was no date or name of the writer on the note.During a concurrent interview and record review with the Licensed Vocational Nurse (LVN), on 4/17/26 at 12:44 a.m., the LVN confirmed that the Discharge Summary and Post-Care Instructions, dated 3/20/26, did not indicate the discharge location address and home health services agency name and contact information. The LVN also stated that the form should be complete.During a telephone interview with FM A, on 4/20/26 at 9:04 a.m., FM A stated that Resident 1 was locked out and kicked out of FM B's residence. FM A also stated Resident 1 had no key to the house. FM A stated that FM B was not in the house and was in a skilled nursing facility. FM A further stated that she informed the facility staff that she was looking for a place for Resident 1 to stay after discharge and not to discharge the resident.During a telephone interview with the Agency Director (AD) of a home health agency (HHA), on 4/21/26 at 9:39 a.m., the AD stated that the referral for home health services was received via fax and imported to their intake department on 3/20/26 at 1:31 p.m. The AD further stated the following: On 3/20/26 at 2:08 p.m., HHA did an initial reach out to Resident 1's insurance company. At 6:37 p.m. on 3/20/26, HHA sent an urgent authorization request to the insurance company. On 3/21/26 at 2:49 p.m., the intake coordinator (IC) called Resident 1, however Resident 1 was not available. The IC then informed the HHA that Resident 1 was homeless. On 3/23/26 at 2:33 p.m., the IC called Resident 1 to check in and indicated Resident 1 was not sure when will she be ready. On 3/25/26 at 1:08 p.m., the IC called Resident 1 to check in, and Resident 1 informed the IC that she was living in the street and does not have a place set up. Resident 1 indicated to the IC that she was not in any type of facility and not sure what was happening or when Resident 1 can be seen. The IC also indicated that Resident 1 has been looking for a place but cannot find a place that would accept her. On 3/25/26 at 1:18 p.m., the HHA considered Resident 1 a non-admit and that HHA will not proceed to provide services to Resident 1 because the HHA does not have a way to find or see the resident.During a telephone interview with the Social Services Assistant (SSA), on 4/20/26 at 1:19 p.m., the SSA stated that the HHA informed her that Resident 1 was safe. The SSA stated she does not recall when she spoke with the HHA.During a telephone interview with the SSA, on 4/21/26 at 9:45 a.m., the SSA stated that the HHA referral was sent on 3/20/26. The SSA also stated that the best practice in the facility was to send the HHA referral prior to discharge. The SSA further stated that the facility will start coordinating the HHA referral any time before the resident leaves the facility.During an interview with the Facility Driver (FD), on 4/21/26 at 12:51 p.m., the FD stated that he does not remember what happened after he dropped off Resident 1 in the specified address.During an interview with the DSS, on 5/6/26 at 12:28 p.m., the DSS stated that the reason for Resident 1's discharge was that insurance issued the last covered date. The DSS stated that Resident 1 was not asked prior to discharge on [DATE] if there were any changes to the home situation. The DSS stated Resident 1 did not approach her which indicated that the home situation has not changed. The DSS further stated that family support involved FM A and FM B but did not talk to them. The home situation was not discussed prior to discharge date because Resident 1's discharge plan has not changed. The DSS stated the facility was not required to call Resident 1 after discharge. The DSS also stated that the FD informed the DSS that Resident 1 was dropped off at the address that was in the Notice of Proposed Transfer/Discharge.Review of HHA's Client Coordination Note Report, dated 3/21/26, indicated Pt is homeless - she will call us back when she finds out where she will be staying.Review of Resident 1's HHA's Client Coordination Note Report, dated 3/23/26, indicated Called patient to check in, she said she is still recovering and is not sure when she will be ready. She appreciated the call and said it would be a slow recovery - she was getting another call so we disconnected. Pending servicing address. Pending address/screen/MD conf.Review of Resident 1's HHA's Client Coordination Note Report, dated 3/25/26, indicated Called patient to follow up and check in. She said she is living on the street and does not have a place set up for her. She said she is not in any kind of facility and is not sure what was happening with us or when we can see her. She stressed she has nowhere for us to see her at this time, has been looking but cannot find a place that can accept her. She will keep us updated if anything changed. I asked to follow up with her later, she agreed.Review of Resident 1's HHA's Client Coordination Note Report, dated 3/25/26, indicated Reason for HH non admit. Comments: patient does not have a place to reside where we can provide services.Review of Resident 1's acute care hospital (ACH) AA's ED (Emergency Department) final report, dated 4/2/26, indicated Resident 1 was brought in by ambulance to the ER (Emergency Room) after being found on the floor by EMS (Emergency Medical Services, trained personnel that provide care and transport) of a fast food place with left facial droop, left-sided weakness and slurred speech. Resident 1 was admitted to the ICU (Intensive Care Unit, a specialized unit for extremely ill or severely injured patient that required constant monitoring) for acute stroke (lack of blood flow to a part of the brain), septic shock (blood pressure drops to a dangerous low level caused by a severe infection), acute UTI (Urinary Tract Infection, infection of the bladder or kidney) and acute respiratory failure (lungs cannot release enough oxygen into the blood).Review of Resident 1's ACH AA's Discharge Summary final report, dated 4/6/26, indicated Given patient's recent brain surgery patient would not be a good candidate for anticoagulation (medication used to stop the blood from forming), decision was made to transfer patient for possible thrombectomy (a procedure to remove a blood clot). discharged to another ACH on 4/6/26.Review of Resident 1's acute care hospital ACH AA's Consult Note final report, dated 4/3/26, indicated currently at a homeless shelter.Review of Resident 1's acute care hospital ACH BB's admission H&P (History and Physical, initial and comprehensive assessment of the patient), dated 4/7/26, indicated MRI brain later demonstrated two acute parietal infarcts (damage to a part of the brain as a result of a sudden loss of blood supply to the brain). Her course was complicated by persistent hypotension (low blood pressure) requiring ICU admission.Given the severity of her PE (pulmonary embolism, blood clot in the lungs), inability to anticoagulated, and ongoing hemodynamic instability (not enough blood flow in the body) .decision was made to transfer the patient for urgent pulmonary thrombectomy.The patient is homeless.Review of Resident 1's ACH BB's physician progress note, dated 4/11/26, indicated Patient was discharged to SNF in San [NAME] and discharged to her car in Manteca. Patient is homeless and was living out of her car.Review of the DSS's Essential Duties & Responsibilities, undated, indicated Care Planning: Evaluate social and family information and psychological needs to develop comprehensive care plans; establish courses of action by exploring options and setting goals with families. Discharge Planning: Coordinate with the interdisciplinary team and outside agencies to ensure safe transitions, including arranging equipment and agency referrals.Review of the SSA's key responsibilities, undated, indicated Assist residents and families with care planning, transitions, and psychosocial needs; help complete required documentation, assessments, and progress notes in compliance with state and federal regulations; communicate with interdisciplinary team members to ensure resident needs are met; participate in discharge planning and community resource coordination.Review of the facility's policy and procedures (P&P), titled Transfer or Discharge for Resident in Facility Less Than Thirty (30) Days, undated, indicated When a resident has not resided in the facility for thirty (30) days, written notice of an impending transfer or discharge will be given as soon as it is practicable but before the transfer or discharge.According to AFL 25-17 (All Facilities Letter, an official notice issued by the California Department of Public Health to all licensed or certified health facilities providing essential updates, guidance, and policy changes that must be followed to maintain compliance with state and federal regulations), dated 5/28/25, indicated The facility's notice must include all of the following at the time notice is provided.the specific location (address if the location is a residence) to which the resident is to be transferred or discharged .Notice must be provided at least 30 days prior to the transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:.a resident has not resided in the facility for 30 days.In these exceptional cases, the notice must be provided to the resident, resident's representative(s) if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge.Review of the facility's P&P, titled Discharge Summary and Plan, undated, indicated The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting.The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge.Residents are periodically assessed for their interest in returning to the community. If the resident indicates an interest in returning to the community, the facility inquires about support in place. This may include the capacity of the resident's caregivers at home. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record.Review of the California Department of Aging Long-Term Care Residents' Rights, dated 2026, indicated The facility must provide notice and ensure safe transfer or discharge.

Based on observation, interview and record review the facility failed to promote the patient rights for one of five residents (Resident 2). This failure had the potential to negatively affect Resident 2's psychosocial wellbeing and sense of security.Findings:Review of Resident 2's undated admission Record indicated, she was admitted to the facility on [DATE], with diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), type II diabetes mellitus (high levels of sugar in the blood), pneumonia (infection in the lungs), sepsis (the body's response to a severe infection).Review of Resident 2's Notice of Room or Roommate Change, dated 4/6/26, indicated the reason for Resident 2's room change was renovations. The notice indicated Resident 2 will be moved from patient room (PR) CC to PR DD.During an interview with the Administrator (ADM), on 4/15/26 at 12:04 p.m., the ADM confirmed PR CC was occupied by another residents. The ADM also stated Resident 2 was not returned to PR CC to minimize the impact of moving residents back and forth.Review of the Social Service Note, dated 4/9/26, indicated SSD asked resident if she'd like to stay in current room or move to different.During a concurrent interview and record review with the Director of Social Services (DSS), on 4/15/26 at 12:56 p.m., the DSS confirmed that she used different room when Resident 2 was asked if she wanted to move rooms.During an interview with Resident 2's Responsible Party (RP), on 5/1/26 at 12:23 p.m., the RP stated that she told the Admissions Director (AD) to move Resident 2 back to the room once the work was done. The RP also stated that two days later the PR CC was occupied by a different resident.During an interview with the AD, on 5/1/26 at 1:19 p.m., the AD stated Resident 2's RP asked if Resident 2 can be moved back to PR CC once work in the room was done. The AD stated the RP was told that they cannot assure that Resident 2 will be moved back to PR CC once work is done to the room.During an interview with the Director of Nursing (DON), on 5/7/26 at 11:22 a.m., the DON stated they will work with the family to find an appropriate room. During a telephone interview with the DON, on 5/14/26 at 1:39 p.m., the DON stated Resident 2 was in PR CC from 4/11/23 until 5/16/24 when she was transferred to an acute care facility. The DON also stated that Resident 2 was in PR EE from 5/27/24 to 5/28/24 after she was transferred back to the facility from acute care facility. The DON further stated that Resident 2 was moved back to PR CC on 5/29/24 until 4/6/26. The DON also stated that he has not heard the staff ask Resident 2 if she wanted to move back to PR CC.Review of the undated facility's policy and procedures (P&P), titled Resident Rights, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; b.be treated with respect, kindness, and dignity.

Based on observation, interview, and document review, the facility failed to follow their policy and procedure regarding foods brought to residents by family and visitors when the facility did not educate family and visitors to prepare and transport food using safe handling practices outlined in the policy and procedure. This failure increased the risk of family members bringing contaminated food to residents leading to food born illness for 147 who ate food by mouth out of a census of 153.Review of the undated policy and procedure titled Foods Brought by Family/Visitors, showed family/visitors are asked to prepare and transport food using safe food handling practices, including: safe cooling and reheating processes, holding temperatures, preventing cross-contamination with raw or undercooked foods, and hand hygiene. During an observation and interview on 3/10/26 at 1:28 Licensed Vocational Nurse (LVN) L stated food brought in for residents by family and visitors could be stored for residents in the refrigerator located in a pantry room at a nursing station for up to three days. Family members bringing food for residents was confirmed when a person who identified herself as a family member placed food in the refrigerator, labeled with a resident's name. The bag of food contained food including soup and pureed food, all in reusable plastic containers. In an interview with the Director of Staff Development (DSD) and the Registered Dietitian (RD) on 3/11/26 at 10:26 a.m., DSD and RD were asked if family members/visitors who brought in food for residents were educated by the facility regarding safe food handling practices. DSD stated nursing checks for appropriate texture of food according to resident diet orders. When asked specifically about education regarding safe cooling of food, reheating processes, holding food temperatures, and preventing cross-contamination with raw or undercooked foods, RD stated we don't have control over what the family does at home. In an interview with the Director of Nursing (DON) and the Administrator (ADM) on 3/11/26 at 11:15 a.m., when asked if facility provides family members/visitors information regarding safe food handling practices for family members who bring in food for residents, the DON stated nursing was responsible what was in their scope of practice which was ensuring the texture is appropriate for the diet order. DON stated for anything (related to resident food) outside of the scope of practice for nursing, it would be referred to the RD, who would provide information to families during family care conferences. In an interview on 3/13/26 at 10:40 a.m., ADM stated a document about food brought in for residents from outside was provided in the resident admission packet. ADM stated the purpose of the document was to instruct family members regarding facility expectations on safe food practices. In an interview with ADM and facility document review on 3/13/26 at 5:07 p.m., the document titled Outside Food for a Resident dated 2026, was reviewed. ADM confirmed the document was not as detailed as the facility policy and procedure titled Foods Brought by Family/Visitors, but had some information on safe food handling, such as food made with raw eggs should not be brought in. ADM confirmed the Outside Food for a Resident document did not include safe cooling, reheating processes, holding temperatures, and preventing cross-contamination with raw undercooked foods.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation during storing and preparing food in accordance with professional standards for food service safety when:Three of three ice machines (one in kitchen, and two located in nursing station areas) were not clean.The strength of sanitizer used to sanitize a kitchen food preparation table was not an appropriate strength.A kitchen industrial can opener and its base were not clean.These failures had the potential to increase the risk of food contamination to the residents in the facility for 147 residents who ate food by mouth out of a facility census of 153.1. During a concurrent observation and interview on 3/10/26 at 10:03 a.m. with the Maintenance Supervisor (MS) in the kitchen, the ice machine was observed. MS stated maintenance staff cleaned the inside of the ice machine quarterly, and this ice machine in the kitchen was cleaned about three weeks ago. MS opened the ice machine so the inside components could be observed. There was black residue along the surface and corners of the cover for the water distribution tube (a component mounted on top of the evaporator plate to ensure water flows evenly over the freezing surface of the evaporator plate) located above the evaporator plate (a metal grid where water runs over and freezes to form ice cubes). On the evaporator plate frame, there was yellow residue on the surface, and it was rough to touch. By using white paper towel to wipe along the surface on the top plastic frame of evaporator plate, black residue was wiped off. MS confirmed the black residue, and he stated the ice machine was not considered clean. MS stated the yellow residue was the hard water build-up, and he had not done anything with the ice machine to address hard water build-up issue. As the observation and interview continued for the ice machine on 3/10/26 at 10:10 a.m., under the ice machine, there were three drainpipes. One of the drainpipes, which MS stated was a drain from the ice machine, had thick, dark brown residue build-up at the end of the drainpipe. Maintenance Assistant (MA) J removed the residue from the drainpipe. The residue was hard. MS stated it was likely the mineral build-up. MS stated the drainpipes were not checked the last time the ice machine was cleaned.During an interview on 3/11/26 at 2:15 p.m. with MS, MS stated he needed to pay more attention to the drainpipes under the ice machine, and clean as needed.During a concurrent observation and interview on 3/10/26 at 2:10 p.m. with MS in the pantry room at the mid-term nursing station, ice machine was observed. Ice machine dispenser had crusty, white, yellow, and pinkish residue around the chute. Using paper towel to wipe the chute, the surface was rough to touch. MS stated there used to be some sort of insulation around the chute surface. MS stated he dared not to try to remove or clean the rough surface because he was afraid it might affect the function of the ice machine. MS stated he guessed the rough residue was from the moisture of the ice machine.During a concurrent observation and interview on 3/10/26 at 2:29 p.m. with MS in the pantry room at the short-term nursing station, ice machine was observed. Ice machine dispenser also had crusty, white, yellow, and pinkish residue around the chute. Using paper towel to wipe the chute, the surface was rough to touch. Again, MS stated there used to be some sort of insulation around the chute surface. He stated it might be the mineral build-up.According to the 2022 Federal Food Code, food-contact surfaces are to be smooth, free of open seams, cracks, chips, inclusions, pits, and similar imperfections. Food-contact surfaces are to be clean to sight and touch. In addition, nonfood-contact surfaces are to be kept free of an accumulation if debris and are to be free of unnecessary projections, crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.2. During a concurrent observation and interview in the kitchen on 3/10/26 at 9:25 a.m. with Dietary Aide (DA) B and Dietary Manager (DM), DA B was observed to using a cloth soaked with a sanitizer from a red bucket to wipe down a food preparation table. DA B was asked to test the strength of the sanitizer in the red bucket that she was using. She used a test strip from a QAC (Quaternary Ammonium Compound; a type of sanitizer) test Strip. DM was asked to test the sanitizer. He dipped a test strip in and out of the sanitizer, then compared it to the color comparison chart on the test strip container. After the manufacturer's 5 second wait time for comparing the test strip to the color chart on the test strip bottle, DM stated the test strip showed 50 parts per million (ppm). DM stated the sanitizer was not strong enough, it should be between 200-400 ppm according to the sanitizer manufacturer's poster posted on the wall above the three-compartment sink, which showed sanitizer strength 200-400 ppm.According to the facility's Policy and Procedure (P&P) titled Sanitization dated 2001, all equipment are cleaned and sanitized using heat or chemical sanitizing solutions. Service area wiping cloths are placed in a chemical sanitizing solution of appropriate concentration. 3. During a concurrent observation and interview on 3/9/26 at 9:38 a.m. with the DM in the kitchen, an industrial can opener was stored in a base attached to end of the trayline table. There was orange residue on the blade of the can opener. DM stated the residue looked like jelly. He stated the kitchen staff cleaned the can opener once a day, not after each use. However, DM stated it was not okay to use the can opener if the blade was soiled. DM stated he guessed the can opener should have been cleaned after each use. In a consecutive observation and interview on 3/9/26 at 9:39 a.m., the base of the can opener attached to the preparation table was observed to have black, brown, orange residue build-up on the surface and embedded in the seam where the base attached to the table. DM stated it did not appear it was getting cleaned every day. It should have been cleaned every day.Review of the facility's P&P titled Sanitization, dated 2001, showed all equipment and counters are kept clean. According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and other debris.

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment for residents and staff when:Cloth straps used to hold ice chests were not clean.The floor around a metal cabinet in the kitchen was not clean, and the floor in the kitchen walk-in freezer was not clean.A kitchen's air conditioner surface was not clean.A large portion of paint was detached from the wall surface in the kitchen.The baseboard around the kitchen trayline table in the kitchen was broken and cracked.The vent in the kitchen's chemical room was not clean.There was no air gap for the kitchen food preparation sink drain.These failures had the potential to provide harborage for pests and/or contaminate equipment leading to contamination of food for 147 residents out of a census of 153.Findings:Review of the facility's policy and procedure titled, Sanitization, dated 2001, indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All . equipment are kept clean, maintained in good repair. Review of the facility's policy and procedure titled, Maintenance Service, dated 2001, indicated, Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards.According to the 2022 Federal Food Code, physical facilities are to be maintained in good repair and cleaned as often as necessary to keep them clean. 1. During a concurrent observation and interview on 3/9/26 at 9:08 a.m. with the Dietary Manager (DM) in the kitchen, two ice chests were observed. Each ice chest was held by two cloth straps in a cart. DM stated the ice chests were used to store ice from the kitchen for use on the units during weekend when the kitchen was closed because the ice machines in the units were not working. The cloth straps holding wrapped around the ice chests had a significant amount of yellow and black residue on the surfaces. DM stated it looked stained.During an interview on 3/12/26 at 11:24 a.m. with Infection Preventionist (IP), a photo of cloth straps used to hold the ice chests was presented, IP stated the straps did not look clean and should have been replaced or cleaned. She stated even if the straps were outside of the ice chest, contamination could occur because people would handle the outside of the ice chest. During an interview on 3/13/26 at 7:12 p.m. with the DM, DM stated the ice was used for purposes such as keeping food/beverages cold on the medication carts. 2. During a concurrent observation and interview on 3/9/26 at 9:10 a.m. with the DM in the kitchen, there was a tall metal filing cabinet in proximity to the trayline steam table. In the space between the wall and the cabinet, there was a significant amount of debris on the floor, including black bits and a dead bug which DM stated was a dead cockroach. DM pulled the cabinet out from the wall and more black and brown debris was visible around the space where the cabinet was stored. DM stated the floor around this cabinet was not getting cleaned daily because the cabinet was heavy to move. During a concurrent observation and interview on 3/9/26 at 9:22 a.m. with the DM in the walk-in freezer in the kitchen, on the floor by the back wall under the food racks, there was debris, which appeared to be pieces of food, bits of paper, and brown residue. DM stated the staff did not remove the racks when they cleaned the room, so the residue was trapped under and behind the racks.3. During a concurrent observation and interview on 3/9/26 at 9:15 a.m. with the DM in the kitchen, the air conditioner on the wall in proximity to the trayline table was observed to have gray fuzzy residue on the top surface. DM stated it was dusty and it was supposed to be clean. He did not schedule staff to clean the area. DM stated the surface of the air conditioner should have been cleaned by kitchen staff once a week whether or not it was in use. 4. During a concurrent observation and interview on 3/9/26 at 9:13 a.m. with the DM in the kitchen, the wall on the left side of a cabinet in proximity to the trayline table, was observed to have over 1 foot by 1/2 foot paint surface pulled away from the wall. DM thought the wall may have been damp at one time to cause the paint to detach from the wall. DM stated he did not report this condition to the maintenance.During a concurrent observation and interview on 3/9/26 at 11:47 a.m. with the Maintenance Supervisor (MS) in the kitchen, the wall near the metal cabinet was observed. MS confirmed it was the paint that was coming off the wall. MS stated he was not aware of this condition. MS stated the maintenance staff did the rounds in the kitchen once a week, but the staff did not notice the wall because the cabinet was in the way. MS also stated kitchen staff were able to report maintenance needs which were usually done via text message.According to the 2022 Federal Food Code, wall materials are to be attached so they are easily cleanable. Indoor wall construction is to be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface. 5. During a concurrent observation and interview on 3/9/26 at 9:44 a.m. with the DM in the kitchen, baseboard around the trayline was broken and cracked. Some chunks were missing, and the edges of baseboard were jagged. DM stated dirt and dust could get stuck in the crevices when the baseboard was cracked and not smooth.According to the 2022 Federal Food Code, materials for indoor floor surfaces shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted.6. During a concurrent observation and interview on 3/9/26 at 9:47 a.m. with the DM in the chemical room in the kitchen, the vent on the wall was observed to have gray residue on the surface. DM stated it was dusty and maintenance staff were responsible for cleaning the vents.During a concurrent observation and interview on 3/9/26 at 11:47 a.m. in the chemical room in the kitchen, MS stated he was not aware of the vent in the chemical room in the kitchen. Normally, the main vents in the kitchen were cleaned by maintenance staff, but they missed this one. Review of the facility's policy and procedure titled, Departmental (Maintenance) - Plumbing, HVAC, and Related Systems, dated 2001, indicated, . General Guidelines - HVAC. 6. Clean air vents and air handling units at least annually. 7. During a concurrent observation and interview on 3/10/26 at 10:18 a.m. with the MS in the kitchen, a drainpipe from the food preparation sink was plumbed directly into the wall without an air gap (a gap that prevents contaminated water from flowing back into the food equipment). MS stated the drainpipe connected directly to the grease trap.According to the 2022 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1.The Licensed Nurse did not establish a sterile field on the overbed table prior to performing the PICC line (a long, flexible tube inserted through a peripheral arm vein and advanced into a large vein near the heart) dressing change for Resident 7.2. Resident 73's unlabeled nebulizer mask (plastic mask and tubing used as a connection from compressor to deliver mist to client )that was attached to the machine was exposed and touching the bedside table and nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration) was hanging at the side of his wheelchair and the two prongs were touching the floor;3. Registered Nurse E failed to perform hand hygiene between tasks that required hand washing;4.Resident 168's was on contact precaution and the signage outside her room was Enhance Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, are bacteria and microorganisms resistant to one or more classes of antimicrobial agents, making infections difficult to treat] in nursing homes.) and5.Resident 40 was not placed on Enhance Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, are bacteria and microorganisms resistant to one or more classes of antimicrobial agents, making infections difficult to treat] in nursing homes.) These failures had the potential to spread infections to residents, staff, and visitors.Findings: 1.A review of Resident 7's clinical record indicated that Resident 7 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to an internal right hip prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better). A review of Resident 7's physician order dated 1/10/2026 indicated: IV (a method of administering fluids, medications, or nutrients directly into a vein) PICC line (a long, flexible tube inserted through a peripheral arm vein and advanced into a large vein near the heart) dressing change to the RUA (right upper arm). Cleanse using a PICC dressing kit, followed by application of a Bio patch and waterproof transparent dressing weekly, beginning 1/15/2026. During an observation on 3/12/2026 at 2:15 p.m. in Resident 7's room, RN N was observed changing the resident's PICC dressing. RN N did not establish a sterile field on the overbed table; instead, she placed a pair of sterile gloves on the resident's blanket over the resident's body, opened them there, and donned them. The PICC dressing kit was also placed and opened on the resident's blanket over the resident's body. During a phone interview with RN N on 3/12/2026 at 4:40 p.m., RN N confirmed that she had not set up a sterile field on the overbed table. She stated that she should have cleaned the overbed table, placed a barrier drape, and placed equipment on the table to prevent infection. A review of facility policies and procedures titled .Central Venous Catheter Care and Dressing Changes dated 2001 indicates that.clean the over the bed table with soap and water, or alcohol, place equipment on table. 2. During an initial observation tour of the facility and interview on 3/9/26 at 9:04 a.m., Resident 73's NC that was attached to the portable oxygen at the back of his wheelchair was hanging and the nasal prongs were touching the floor. Resident 73 acknowledged the observation and stated he has portable oxygen at the back of his wheelchair and NC was attached to it. Resident 73 further stated that NC has been touching the floor since last night and he was using the wheelchair when he is going out for dialysis. During a concurrent observation and interview on 3/9/26 at 9:05 a.m., with Registered nurse E (RN E), She confirmed the above observation and stated NC attached to the portable oxygen at the back of Resident 73's wheelchair should not have been hanging and touching the floor. Review of Resident 73's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including respiratory disorders , end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those kidneys that have lost normal function). Review of Resident 73's Minimum Data Set (MDS, an assessment tool), dated 2/6/26, indicated he was cognitively intact with a brief interview for mental status (BIMS) score of 15. Review of the Physician (MD) Order dated 1/28/26, indicated Oxygen - 2 Liters/Min Via Nasal Cannula (Continuous) (Medical DX:SOB).Goal To Maintain 02 Sats Greater Than 90% and Change Nasal Cannula (NC) every Sunday at night shift. Review of the undated facility's policy, titled Department (Respiratory Therapy)- Prevention of infection indicated, the purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. Change the oxygen cannula and tubing seven days, or as needed. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. During a concurrent observation and interview on 3/9/26 at 9:08 a.m., with RN E, She confirmed that Resident 73's unlabeled nebulizer mask that was attached to the machine was exposed and touching the bedside table. RN E stated that nebulizer tubing should have been dated when the staff changed the tubing for Resident #73 and should have been stored inside the plastic bag. Review of the undated facility's policy, titled Administering Medications through a Small Volume (Handheld) Nebulizer indicated, when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days. 3. During an observation on 03/09/2026 at 9:09 a.m., RN E was wearing pair of gloves and using the white ointment she was rubbing the back of Resident #73 . RN E went to the medication cart, removed the pair of used gloves and disposed inside the garbage container attached to the medication cart , open the medication cart with the key from her pocket without performing hand hygiene. During a concurrent observation and interview on 03/09/2026 at 9:10 a.m., RN E confirmed the above observations and stated she forgot to perform hand hygiene after removing the used pair of gloves and should have performed hand hygiene before starting a new task . Review of the undated facility's policy, titled Handwashing/Hand Hygiene indicated Hand hygiene is the primary means for preventing healthcare- associated infections (HAIs) and the transmission of multidrug- resistant organisms (MDROs). This facility requires strict adherence to evidence -based hand hygiene practices (as described in this policy) for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students as Policy Statement. Hand hygiene is indicated before and after touching a resident, after touching the resident's environment or belongings (e.g., bedrails, wheelchair, etc.) and after glove removal. 4. During an initial tour of the facility on 3/9/26 at 9:40 a.m., on 3/10/26 at 9:59 a.m., and on 3/10/26 at 10:05 a.m., Resident 168 has signage outside the door indicated (Enhanced Barrier Precautions or EBP and above the wall of her bed (EBP). No Isolation cart or bin outside the door except inside Resident 168's drawer has gown; hand sanitizer was attached to the resident's room wall and gloves are available inside the room. Facility staff were going in and out in Resident 168's room. During a concurrent observation and interview on 3/10/26 at 10:05 a.m., with the Assistant Director of Nursing D (ADON D) stated that Resident 168 was on EBP and has signage outside the door and above the wall of her bed. ADON D confirmed there was no isolation bin outside Resident 168's room. During a concurrent interview and record review on 3/10/26 at 10:37 a.m., with Infection Preventionist (IP), IP stated she track Residents that is on active precaution, nurses will report to her and she will give them guidance. IP reviewed Resident 168's clinical record and indicated Resident 168 was admitted to the facility on [DATE] and physician (MD) order dated 2/19/26 indicated contact isolation precaution due to ESBL (ESBL, are enzymes produced by certain Gram-negative bacteria that make them resistant to many common antibiotics). IP confirmed that MD order was active and Resident 168 should have a signage of contact precaution with the white bin outside the door, staff should wear gowns, and gloves whenever they enter Resident 168's room. Review of the undated facility's policy, titled Isolation- Categories of Transmission- Based Precaution, indicated Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident- care items in the resident's environment Staff and visitors wear disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed .Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear gloves (clean, non -sterile) when entering the room. 5. During a review of Resident 40's clinical record indicated Resident 40 was admitted to the facility on [DATE] with diagnosis including extended spectrum beta lactamase (ESBL, are enzymes produced by certain Gram-negative bacteria that make them resistant to many common antibiotics), resistance and sepsis (is the body's extreme response to an infection. It is a life-threatening medical emergency.), unspecified. During a review of Resident 10 Physician's order indicated Resident 40 were not placed on EBP. During a concurrent observation and interview outside Resident 40's room on 3/13/26 at 10:25 a.m., with Registered Nurse N (RN N), she stated resident 40 is not on EBP, she further stated there was no EBP signage posted outside Resident 40's room. During a concurrent interview and record review on 3/13/26 at 11:37 a.m., with the IP, the IP stated residents were placed on EBP when they have chronic wounds or MDRO, she further stated they review resident's labs (laboratory) and history to check if resident needs EBP. The IP reviewed Resident 40's clinical record, confirmed the diagnosis of ESBL resistance, the IP reviewed Resident 40's document from the hospital titled, Healthcare facility Transfer Report it indicated Patient Infection Status, patient has MDRO or other lab result requiring precautions and/or has been exposed to MDRO, infection ESBL, Onset 1/25/26, Urine culture. The IP stated Resident 40 should be on EBP and she missed this one. During a review of the facility's policy and procedures titled, Enhanced Standard/Barrier Precautions, undated, indicated, 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained.

Based on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for three of five sampled residents (Residents 73, Resident 42, and Resident 99) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when:Inaccurate access site assessment information and communication with the facility to dialysis center prior (Pre) - Hemodialysis Communication/assessment Records (HCAR's) to dialysis treatment and after (Post) dialysis treatment; and, communication with the dialysis center was not properly coordinated when dialysis center hemodialysis communication observation/ assessment records (DCR) were not completed.These failures may affect the quality of dialysis care being provided to the residents and have the potential to cause resident health complications.Findings: 1. Review of Resident 73's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those kidneys that have lost normal function). Review of Resident 73's Minimum Data Set (MDS, an assessment tool), dated 2/6/26, indicated he was cognitively intact with a brief interview for mental status (BIMS) score of 15. During a concurrent observation and interview on 3/9/26 at 9:04 a.m., with Resident 73, he stated that he was scheduled for dialysis every Tuesday, Thursday and Saturday. Resident 73 further stated that his dialysis access site was on his right upper chest. During a concurrent interview and record review on 3/12/26 at 10:30 a.m., with Licensed Vocation Nurse M (LVN M), LVN M reviewed resident 73's clinical records and stated Resident 73's dialysis access site location is on the right upper chest (RUC) (Perma Catheter, placement of a special (Intravenous) IV line or long, flexible tube inserted into a vein most commonly in the neck and into the heart to allow dialysis to occur) and Resident 73 was scheduled for dialysis every Tuesday, Thursday and Saturday. During a concurrent interview and record review on 3/12/26 at 10:44 a.m., with LVN M, He reviewed Resident 73's Pre- HCAR's dated 3/10/26,3/7/26, 3/5/26, 3/3 /26, 2/28/26, 2/26 /26, 2/24/26, 2/21/26, 2/19/26, 2/17/26, 2/14/26, 2/12/26, 2/11/26, 2/10/26, and 2/7/ 26. LVN M stated Resident 73's dialysis access site was central catheter (permacath) and the location was on the right upper chest (RUC) and the above-mentioned dates were inaccurate access site assessment because dialysis access site (permacath) does not need checking of bruit and thrill as indicated on this HCAR's. Review of Resident 73's hemodialysis care plan on 3/11/26 at 3:56 p.m., dated 1/28/26, indicated Resident 73 Requires Hemodialysis End Stage Renal Failure and has an RUC central Catheter located and is at risk for bleeding at access site. During a concurrent interview and record review on 3/12/26 at 10:55 a.m., with Nursing Supervisor (NS), reviewed Resident 73's Post- HCAR's dated 3/10/26,3/7/26, 3/5/26, 3/3/26, 2/28/26, 2/26/26, 2/24/26, 2/21/26, 2/19/26, 2/17/26, 2/14/26, 2/12/26, 2/11/26, 2/10/26, and 2/7 /26. NS stated that Resident 73's dialysis access site was permacath on his RUC and for permacath, bruit and thrill does not need to be checked as indicated on the above dates of the HCAR's. During a concurrent interview and record review on 3/12/26 at 11:00 a.m., with NS, She reviewed Resident 73's DCR's dated 3/3/26, 2/28/26,2/21/26, 2/17/26,2/7/26, 2/5/26,2/3/26, 1/29/26 and 1/31/26 indicated access site and access location were blank and were not completed. NS stated that facility licensed nurses should have followed up with dialysis center and completed the DCR's for Resident 73's continuity of dialysis care and NS further stated that there were no documentations in the nurse's notes indicating that the licensed nurse called the dialysis clinic to complete the DCR's. 2. During a review of Resident 42's face sheet (summary page of a patient's important information), Resident 42 was admitted to the facility on [DATE] with diagnoses including muscle weakness (generalized) and dependence on renal dialysis (treatment that helps body to remove extra fluid and waste products from blood). During a review of Resident 42's physician's order indicated an order for check dialysis catheter site dressing Qshift (every shift) ., dated 2/13/26. During a concurrent interview and record review on 3/12/26 at 10:05 a.m., with RN N, RN N reviewed Resident 42's clinical records and she stated Resident 42 has right upper chest (RUC), two lumen catheter access for dialysis, RN N stated Resident 42 has no AV graft or shunt (types of vascular access for hemodialysis), she further stated they don't monitor for thrill and bruit for permcath. During a concurrent interview and record review on 3/12/26 at 1:27 p.m., with Assistant Director C (ADON C), ADON C reviewed Resident 42's pre-HCAR's dated 2/21/26, 2/24/26, 2/26/26, 3/2/26, and 3/7/26. ADON C reviewed Resident 42's post- HCAR's dated 3/3/26 and 3/10/26, ADON C confirmed the nurses were checking yes for positive bruit and thrills for above pre-HCAR's and post -HCAR's assessment dates, ADON C stated she expected the nurses to know how to check the permacath and she stated they [nurses] should not be checking for bruit and thrills for permacath. During a concurrent interview and record review on 3/12/26 at 1:23 p.m., with Assistant Director C (ADON C), ADON C reviewed Resident 42's DCR's dated, 2/17/26 and 2/21/26, ADON C confirmed the 42's DCR indicated access site and access location were blank and were incomplete. ADON C further stated she expected the nurses to call the dialysis center if the DCR is incomplete. 3. During a review of Resident 99's face sheet (summary page of a patient's important information), it indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including Resistance to multiple antibiotics and dependence on renal dialysis. During a review of Resident 99's physician order indicated an order for check dialysis catheter site dressing Qshift. dated 1/18/26. During a concurrent interview and record review on 3/12/26 at 10:15 a.m., with Registered Nurse P (RN P), she reviewed Resident 99 and stated Resident 99's access site to right upper chest (RUC) permacath, she further stated for permacath they don't check for bruit and thrills. During a concurrent interview and record review on 3/12/26 at 1:17 p.m., with Assistant Director C (ADON C), ADON C stated Resident 99's has a permacath to right upper chest (RUC), ADON C reviewed Resident 99's pre-HCAR's dates 3/2/26,3/4/26,3/6/26, and 3/11/26, then ADON C reviewed Resident 99's post-HCAR's dated 3/4/26,3/6/26, and 3/9/26. ADON C confirmed the nurses were checking yes for positive bruit and thrills for above pre-HCAR's and post -HCAR's assessment dates, ADON C stated they [nurses] should not answer yes for positive bruit and thrills for permacath. During a concurrent interview and record review on 3/12/26 at 1:13 p.m., with ADON C, ADON C reviewed and confirmed Resident 99's DCR, dated 2/25/26, 3/2/26, 3/4/26, and 3/6/26, indicated, access site and access location were blank and were incomplete. ADON C stated she expected the nurses to call the dialysis center if the DCR is incomplete. Review of the facility's policy titled, Dialysis Service, dated December 2024, indicated each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified facility, ongoing communication and collaboration with the physician and dialysis facility regarding dialysis care and services, ongoing assessment and oversight of the resident before and after dialysis treatments including monitoring the resident during treatments, monitoring for complications, implementing appropriate interventions and using appropriate infection control practices . The policy further indicated assessments will be done, completed and documented in the resident's clinical record and care plan.

Based on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis, especially on the weekend based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS).This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings:During a concurrent interview and record review with the staffing coordinator (SC) on 3/13/2026 at 11:52 a.m., SC reviewed the documents titled, Census and Direct Care Service Hours Per Patient Day, from July through December 2025, indicated the following dates with actual CNA DHPPD were below 2.4: 7/12-2.31;7/13- 2.37;7/19- 2.30;7/20- 2.29;7/21-2.35;7/27-2.22;8/10-2.23;8/17-2.32;8/25-2.35;9/20-2.39;10/11-2.27;11/8-2.39;11/23-2.35;11/29-2.27;11/30-2.3512/6-2.35;12/7-2.32;12/4-2.32;12/20-2.28;12/24-2.32;12/25-2.27 and for the following dates with actual DHPPD were below 3.5: 7/13-3.47;11/23-3.47;11/29-3.46;11/30-3.47;12/6-3.49;12/14-3.47;12/20-3.47;12/24-3.49;12/27-3.46.SC stated that the low staffing back on July - December 2025, were mostly on the weekend and the Direct Care Service Hours Per Patient Day (DHPPD) should have been 3.5 and Certified Nursing Assistant (CNA) Hours Per Patient Day (DHPPD) should have been 2.4. SC further stated that the facility has no staffing waiver.During a review of the All Facilities Letter (AFL) 21-11 dated March 17, 2021, indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facility). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff had appropriate competencies when:Two of two kitchen staff (The Dietary Manager, Dietary Aide B) did not follow manufacturer's instructions for sanitizer test strips when testing the strength of the sanitizer used to clean the food contact surfaces in the kitchen.Three of three staff (The Registered Dietitian, the Dietary Manager, and [NAME] A) did not know and/or follow instructions for fortifying diets. The failure to ensure staff competency for testing sanitizer strength had the potential to increase the risk of food contamination to residents, and the failure to ensure staff competency for fortifying diets had the potential to result in decreased calorie intake for residents receiving a fortified diet.Findings:Review of the job description titled Registered Dietitian dated 2/2024, showed the Registered Dietitian (RD) was responsible for monitoring food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as federal regulations, and inspecting diet trays for conformance to physician's diet orders prior to delivery.Review of the job description titled Dietary Manager dated 2/2024, essential duties included supervising staff in the day-to-day facility operations of assigned areas. Direct and participate in food preparation and service of food that is safe, appetizing, and is of the quality and quantity to meet each resident's needs in accordance with the physician's orders. Ensure work equipment is clean, safe and orderly. 1. During a concurrent observation and interview on 3/10/26 at 9:25 a.m. with Dietary Aide (DA) B and the Dietary Manager (DM) in the kitchen, DA B was asked to test the strength of the sanitizer in the red bucket that she used to wipe down a preparation table. DA B used a test strip from [test strip brand] QAC [Quaternary Ammonium Compound; a type of sanitizer] test strip container. She dipped the test strip in the sanitizer in the red bucket, immediately removed it, and stated the sanitizer was okay to use. DA B did not compare the color of the test strip to the color comparison chart on the test strip bottle. The color of the test strip was observed to be light yellow color.DM was asked to test the sanitizer. He dipped a test strip in and out of the sanitizer, then compared it to the color comparison chart. The color of the test strip was observed to be light yellow. DM stated according to the test strip color chart, light yellow showed the sanitizer strength was 50 parts per million (ppm). DM stated 50 ppm was not strong enough. DM stated the test strip should be a darker green color to show the sanitizer strength was over 200 ppm. During a concurrent interview and record review on 3/10/26 at 9:57 a.m. DM stated there was not a time frame on the test strip instructions to wait after dipping and comparing to the chart. The manufacturer's instructions on the test strip bottle were reviewed, the instructions indicated, 1. Dip strip & remove. 2. Shake off excess water. 3. Wait 5 seconds. 4. Compare. DM confirmed there was a 5-second wait time. He was not aware of these instructions because the test strips were from a new company. DM stated the test strips from the new company were used for about a week. DM stated he thought they had the same instructions as the previous company which required no waiting time frame.During an interview on 3/10/26 at 1:18 p.m. DM stated for any new products such as test strips, the staff should be trained immediately before use. DM stated he was unaware the directions were different with the new test strips, so he did not provide an inservice before using.2. An observation in the kitchen of trayline food service (an assembly-line food service system commonly used in skilled nursing facilities placing resident food onto plates) on 3/9/26 at 12:05 p.m., showed 32 tray tickets (a piece of paper displaying information such as the resident's diet order, allergies, and food preferences) displayed Fortified as part of the diet order. When [NAME] A was asked how the diets were fortified, [NAME] A stated butter was added to the food. When asked which food had butter added, [NAME] A stated a butter packet was placed on the tray instead butter added to the food being served. DM confirmed a butter packet was placed on the tray for fortified diets.During a consecutive interview and record review on 3/9/26 at 1:30 p.m., when RD and DM were asked if there was a fortified menu for the cooks to follow, RD stated she did not know. DM stated he thought there were guidelines for a fortified diet in the diet manual. The section in the 2025 Diet Manual signed by RD and DM on 1/6/26, showed the fortified diet was designed for residents who could not consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The goal was to increase calorie density of foods commonly consumed by the residents. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories included adding extra margarine or butter to food items such as vegetables, potatoes, hot cereal, etc., extra gravy and sauces added to meats, pasta, etc. RD and DM confirmed butter was placed on the tray, but the food served was not fortified upon serving.During an observation, interview, and record review on 3/12/26 at 10:27 a.m., RD stated she just wrote out a schedule for fortified diets and posted it in the kitchen. The schedule showed high calorie cereal for breakfast, extra butter or one ounce of gravy for lunch, and one ounce of melted margarine and one ounce of gravy for dinner. When [NAME] A was asked what foods gravy was added to for the dinner meal for fortified diets, [NAME] A stated he put the gravy in a little cup on the plate, not on the food. Then [NAME] A asked RD if placing the gravy on the side of the food on a cup was correct. RD stated no, the gravy was to go on top of the food for the fortified diet. During an interview and document review on 3/13/26 at 11:05 a.m., DM stated he was not aware of an inservice on fortified diets prior to the start of the survey on 3/9/26.During an interview on 3/13/26 at 19:09 p.m., RD confirmed she was not aware of inservices on fortified diets provided to kitchen staff prior to 3/13/26.

Based on observation, interview, and record review, the facility failed to safely administer medication for one of thirty sampled residents (Resident 108) when licensed vocational nurse I (LVN I) left three routine medications on Resident 108's overbed table unattended, for self-administration. These failures had the potential for unsafe and improper administration of medications.Findings:During a concurrent observation and interview with Resident 108 on 3/9/2026 at 9:31 a.m., inside Resident 108's room, Resident 108 was positioned flat on bed, awake and had three white tablets in a medication cup on top of his overbed table, unattended. The overbed table was positioned in front of Resident 108. Resident 108 stated he needed to sit up to take his medications.During a concurrent observation and interviews with both LVN I and Resident 108 on 3/9/2026 at 9:33 a.m., inside Resident 108's room, LVN I confirmed the observation and stated that he left the medication because Resident 108 was not ready to take his medications yet. Resident 108 stated he needed one big pill to be cut in half and he requested more water. LVN I stated he should not have left the medication at bedside. LVN I further stated, the three white medications were simethicone (it is a generic name for a widely used over-the counter [OTC] anti-gas medication), gabapentin (a prescription medication used primarily to treat nerve pain) 800 milligram (mg - unit of measurement) and aspirin (a common OTC medication used to reduce pain, fever, and inflammation).During an interview with the director of staff development (DSD) on 3/11/2026 at 9:20 a.m., when asked about medication left at bedside, the DSD stated nurses should not leave medication at resident's bedside. The DSD further stated nurses should stay with residents until they take their medications.During a review of the facility's undated policy and procedure titled, Administering Oral Medications, indicated, The purpose of this procedure is to provide guidelines for the safe administration of oral medications.Explain the procedure to the resident. Place medications on the bedside table or tray.Assist the resident to a sitting or side lying position. Offer water to assist the resident in swallowing medications.Remain with the resident until all medications have been taken.

Based on observation, interview and record review, for one of two sampled residents (Resident 158), the facility failed to inform the Responsible Party (RP- person legally responsible to make decisions for a resident) regarding plan of care and/or treatment changes when Resident 158's RP was not informed of physician ordered laboratory tests involving a procedure to obtain a urinary sample. This failure resulted in Resident 158's Responsible Party to unaware of Resident 158's test and procedure for obtaining the urine sample.A review of Resident 158's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including Aphasia (a disorder that makes it difficult to speak), dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), type 2 Diabetes Mellitus (high blood sugar), hemiplegia (paralysis that affects just one side) and hemiparesis (weakness on half of the body) following cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) affecting right dominant side.During observation on 3/10/26 at 11:30 a.m., 3/11/26 at 1:30 p.m., and 3/12/26 at 12:30 p.m., Resident 158 was inside her room and could not response verbally but had eye contact .Review of Resident 158's Minimum Data Set (MDS, an assessment tool) dated 1/19/26, indicated her cognition was impaired and rarely/never understood.During a concurrent interview and record review on 3/13/26 at 10:10 a.m., with Minimum Data Sheet Coordinator( MDSC) , she reviewed resident 158's clinical records and stated that on 2/7/26, NP / Physician Order dated 2/7/26 at 15:22 (3:22 p.m.) indicated new order from NP for Urine Analysis (UA) Culture & Sensitivity (C&S) order noted and carried out by licensed nurse (LN) . MDSC could not provide any documentation that LN notified Responsible Party (RP) about the above order and urine specimen collection was obtained for UA C&S.During a concurrent interview and record review on 3/13/26 at 10:43 a.m., with the Assistant Director of Nursing C (ADON C), reviewed Resident 158's clinical records and stated Nurse practitioner (NP) progress notes dated 2/7/26 indicated Resident 158 was seen by the NP in her room with plan to do urine analysis (UA), culture and sensitivity (C&S), which the assessment and plan was discussed with Physician (MD). on 2/7/26, NP / Physician Order dated 2/7/26 at 15:22 (3:22 p.m.) indicated new order from NP for UA C&S order noted and carried out by licensed nurse (LN). ADON further stated that on 2/11/26 due to Resident 158's incontinent of urine straight catheterization was used when urine sample was obtained for UA C&S.During a concurrent interview and record review on 3/13/26 at 10:45 a.m., with ADON C, She reviewed Resident 158's clinical records and could not show documentation the Resident 158's RP was notified of the urine sample collection procedure as ordered by MD on 2/7/26 for UA C&S. ADON stated that the LN was supposed to call the RP and document the notification.During a concurrent interview and record review on 3/13/26 at 10:57 a.m., with ADON C, She reviewed Resident 158's clinical records and stated that Nurse's Notes dated 2/11/26 at 8:35 a.m., indicated urinalysis results reviewed , results relayed to MD. Pending any new order by the LN and a change in condition evaluation record dated 2/11/26 indicated LN notified Resident 158's RP on 2/11/26 at 10:00 a.m., about UA result but not the laboratory tests or diagnostic procedure that was done on 2/7/26. ADON further stated that Resident 158's Care Plan (CP) dated 2/11/26 indicated Resident 158 has abnormal UA results.During telephone interview with Resident 158's RP on 3/13/26 at 2:37 p.m., Resident 158's RP stated that the facility staff did not inform her of the NP plan and physician's order for UA C&S and urine sample was obtained from her mother on 2/7/26. RP further stated that She was expecting the facility staff to notify her for any changes in her mother's changed of condition and plan of care .Review of the undated facility's policy, titled Change in a Resident's Condition or Status, the policy statement indicated facility promptly notifies the resident, his or her attending physician , and the resident representative of changes in the resident's medical/mental condition and/ or status. Regardless of the resident's current mental or physical condition, a nurse or health provider will inform the resident and /or representative of any changes in his/her medical or nursing treatments.The nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to maintain respect and dignity for four of five sampled residents (Residents 17, 167, 28, and 7) when:1.Registered nurse F (RN F) was standing while feeding Resident 17 in bed, near the room's opened door;2.Resident 167's care instructions were posted above Resident 167's head of bed's wall uncovered; and,3. Resident 28 did not have a covering bag to conceal his drainage bag; and,4. The Licensed Nurse wrote her initials and the date on the tape while it was on Resident 7's arm during dressing change.These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1.Review of Resident 17's clinical record titled, admission Record, indicated Resident 17 was admitted to the facility with diagnoses including heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs), dementia (decline in mental capacity affecting daily function), and dysphagia (difficulty in swallowing). Review of Resident 17's quarterly minimum data set (MDS – a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 17's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 03 (a score of 0 to 07 indicates severe cognitive impairment, 08-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 3/9/2026 at 12:58 p.m., in front of Resident 17's opened room door, Resident 17 was repositioned by RN F in bed, and started feeding her while standing at the left side of Resident 17's bed. Resident 17 was positioned lower than RN F. During a concurrent observation and interview with certified nursing assistant G (CNA G) on 3/9/2026 at 1:05 p.m., inside Resident 17's room, CNA G entered the room and assisted Resident 17 to sit at the edge of the bed and positioned her overbed table with her lunch in front of her. Resident 17 was observed to eat independently. CNA G confirmed observation with RN F and stated the staff should reposition the residents first during mealtime and assist them as needed. CNA G stated the staff should sit beside the residents during meal assistance. During an interview with RN F on 3/9/2026 at 1:07 p.m., RN F confirmed above observation and stated she should have sat beside Resident 17 while feeding her for Resident 17's comfort. During an interview with the director of staff development (DSD) on 3/11/2026 at 9:25 a.m., the DSD stated, it's okay to feed resident while standing as long as the resident is not showing any parts of her body. During a review of the facility's policy and procedure titled, Assistance with Meals, date revised 3/2022, indicated, Resident who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over resident while assisting them with meals. 2.Review of Resident 167's clinical record titled, admission Record, indicated Resident 167 was admitted to the facility with diagnoses including cerebral ischemia (also known as cerebrovascular or brain ischemia, occurs when there is a shortage of oxygen or blood flow to the brain caused by a blockage or bleeding in the arteries that supply blood to the brain), wedge compression fracture (a type of spinal break where the front part of a vertebra collapses, while the back remains intact) of first lumbar vertebra (the topmost bone of the five vertebra in the lower back [lumbar spine], located just below the chest [thoracic] spine), and benign neoplasm of meninges (a noncancerous tumor that grows from the protective membranes surrounding the brain and spinal cord). Review of Resident 167's quarterly MDS assessment dated [DATE] indicated Resident 167's BIMS score was 03. During an observation on 3/9/2026 at 10:59 a.m., in Resident 167's entrance door room, Resident 167 was in bed, asleep, and observed she had two care instructions posted above the head of bed's wall. The care instructions were displayed and could be read through Resident's 167's entrance door. The first care instruction posted indicated, Please DO Not remove splint from finger (if so, please put it back on). The second care instruction posted indicated, Please use rash oilment [ointment] when changing my diaper. Thank you! During a concurrent observation and interview with licensed vocational nurse H (LVN H) on 3/10/2026 at 9:331 a.m., inside Resident 167's room, the two care instructions were still posted above Resident 167's head of bed wall. LVN H confirmed above observation and stated the care instructions were posted there for a while now. LVN H further stated the care instructions should be removed or covered for Resident 167's confidentiality. During an interview with the DSD on 3/11/2026 at 9:23 a.m., DSD stated there were times families would post care instructions and nurses should speak with the family about it. DSD further stated, nurses should cover the care instruction if the family requested to have it posted During a review of the facility's policy and procedure titled, Dignity, date revised 2/2021, indicated, Residents are treated with dignity and respect at all times.Staff protect confidential clinical information. Examples include the following:.Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room.Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door). 3.A review of Resident 28's clinical record indicated that Resident 28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including acute cholecystitis (the inflammation of the gallbladder, usually caused by gallstones blocking the bile duct) and an encounter for surgical aftercare following surgery on the digestive system on 12/18/2025. A review of Resident 28's physician order dated 2/22/2026 indicates measuring the RUQ (right upper quadrant) cholecystostomy (a medical procedure used to drain the gallbladder through either a percutaneous or endoscopic approach) drain every shift. During a concurrent observation and interview with Resident 28 on 3/10/2026 at 11:10 a.m. in the hallway, Resident 28 was sitting in a wheelchair with a drainage bag resting on his legs. No covering bag or privacy device was in place to conceal the drainage bag. Resident 28 stated that no covering bag was available to conceal the drainage bag. During a follow-up interview on 3/11/2026 at 10:29 a.m., Resident 28 stated that the lack of a proper covering bag caused the drainage bag to pull at the insertion site, resulting in pain. Resident 28 further stated feeling embarrassed when the drainage bag was exposed. During an interview with Licensed Vocational Nurse (LVN) Q on 3/11/2026 at 10:39 a.m., the LVN Q confirmed that Resident 28 had a cholecystostomy drainage bag and stated that a covering bag should be provided for privacy and dignity. 4. A review of Resident 7's clinical record indicated that Resident 7 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to an internal right hip prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better). A review of Resident 7's physician order dated 1/10/2026 indicated: IV (a method of administering fluids, medications, or nutrients directly into a vein) PICC line (a long, flexible tube inserted through a peripheral arm vein and advanced into a large vein near the heart) – Change (PICC) Dressing Site: RUA (right upper arm). Cleanse with PICC dressing kit followed by application of a Bio patch and waterproof transparent dressing weekly, beginning 1/15/2026. During an observation and interview with RN N on 3/12/2026 at 2:15 p.m. in Resident 7's room, after completing the PICC line dressing change, RN N placed a piece of tape directly on the resident's right arm and wrote her initials and the date on the tape while it was on the resident's right arm. During a phone interview on 3/12/2026 at 4:40 p.m., the RN N confirmed that she wrote her initials and the date on the tape while it was on the resident's arm. She acknowledged that, to maintain dignity, the initials, date, and time should be written on the tape prior to placing it on the resident. A review of the facility's polices and procedures titled Dignity indicates that .each resident shall be cared for in a manner that promotes and enhances the his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem.Residents are treated with dignity and respect at all times.staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and document review, the facility failed to offer provide a substitute of similar nutritional value for a menu item (milk), when Resident 133 preferred not to have milk at lunch meals. The failure to provide a substitute item of similar nutritional value had the potential to result in Resident 133 not receiving the nutrients meant to be provided by the planned menu leading to an inadequate nutrient intake.The menu spreadsheet titled Spring Cycle Menus dated 3/11/26, showed 8 ounces of milk on the menu for the Regular diet.During an observation in the resident dining room on 3/11/26 at 12:51 p.m., Resident 133 sat at a table eating her facility provided lunch. For her beverage, Resident 133 had one cup of juice in front of her. Resident 133's tray ticket (a piece of paper displaying information such as the resident's diet order, allergies, and food preferences) which was also on the table in front of her, showed Resident 133 was on a Regular diet, and Beverages: Coffee, 4 oz (ounce) Apple. During an interview with the Registered Dietitian (RD) and the Dietary Manager (DM) on 3/11/26 at 2:27 p.m., RD confirmed the menu was analyzed and should meet the DRIs (Dietary Reference Intake; a comprehensive set of scientifically developed evidence-based nutrient reference values for healthy populations in the U.S. They define the recommended daily intake for vitamins, minerals, and macronutrients, aimed at preventing deficiencies, reducing chronic disease risk, and preventing toxicities). DM confirmed milk was on the menu each day for each meal. DM stated Resident 133 did not dislike milk. DM stated he asked residents their preferences for beverages with their meals but a substitute for milk was not offered if residents preferred not to have milk for their meal/s. RD and DM agreed coffee and apple juice, which were Resident 133's beverage preference for lunch, did not provide the same nutrients as milk.During an interview on 3/13/26 at 10:18 a.m., DM stated he asked residents their beverage choices for meals but also offered snacks to residents which could be provided in between meals or on the meal tray. DM stated snacks could include milk products, but choices included food items that did not necessarily provide the same nutrients as milk, such as Jello and fruit. DM explained all residents were asked snack preferences and were not planned as a substitute for milk.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, individualized, resident-centered care plans for two of 30 sampled residents (Residents 105, and 13) when:1.Resident 105's care plan for diagnosis of alcohol dependence with alcohol induced persisting dementia (a form of permanent brain damage caused by long-term, heavy alcohol consumption) since 1/15/2026, with brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 08 (a score of 00 to 07 indicates severe cognitive impairment, 08-12 moderate impairment, 13-15 patient is cognitively intact) was not developed; and2.Resident 13's care plan for restorative nursing assistant (RNA - a healthcare professional who helps patients regain and maintain their independence and mobility) program for knee splinting (a temporary immobilization of the knee joint using a rigid device [like a brace, splint, or plaster] to keep the leg straight or in a set position) was not developed.These failures had the potential unmet care needs for Residents 105 and 13.Findings:1.Review of Resident 105's clinical record titled, admission Record, indicated Resident 105 was originally admitted to the facility on [DATE] with diagnosis of alcohol dependence with alcohol induced persisting dementia.Review of Resident 105's admission minimum data set (MDS - a federally mandated resident assessment tool) dated 1/16/2026, and 5-day MDS assessment dated [DATE], indicated Resident 105's BIMS score was 08 and had a diagnosis of non-Alzheimer's dementia.During a concurrent interview with social services director (SSD) and record review of Resident 105's 5-day MDS assessment dated [DATE], and list of care plans on 3/12/2026 at 1:26 p.m., SSD confirmed Resident 105 had diagnosis of dementia and her BIMS score was 08. SSD stated there was no care plan developed for Resident 105's diagnosis of dementia.During a concurrent interview with MDS coordinator (MDSC) and record review of Resident 105's 5-day MDS assessment dated [DATE], and list of care plans on 3/13/2026 at 1:26 p.m., MDSC confirmed she couldn't find a dementia care plan in Resident 105's care plan list. MDSC stated there should have been a care plan for dementia. MDSC further stated all nurses are responsible for the development of care plan.During a review of the facility's undated policy and procedure titled, Dementia - Clinical Protocol, indicated, For the individual with confirmed dementia, the IDT [interdisciplinary team - a group of health care professionals from diverse fields who work toward a common goal for residents] will identify a resident-centered care plan to maximize remaining function and quality of life.During a review of the facility's undated policy and procedure titled, Care Plans, Comprehensive Person-Centered, indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.2.Review of Resident 13's clinical record titled, admission Record, indicated Resident 13 was admitted to the facility with diagnoses including secondary malignant neoplasm of brain (brain metastases - are cancerous tumors that spread from primary cancers elsewhere, such as lungs, breast, or colon) and hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following unspecified cerebrovascular disease (CVA/stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function) affecting right dominant hand (the hand naturally prefer and use more often for precise tasks like writing, eating, or throwing).Review of Resident 13's quarterly MDS assessment dated [DATE], indicated a BIMS score of 06 and Resident 13 had five days of RNA program for splint or brace assistance.Review of Resident 13's clinical record titled, Order Summary Report, dated 3/13/2026, indicated an order dated 2/10/2026, RNA for knee Splinting or Bracing Program to (Rt [right] knee) 5x [times] week for 90 days or as tolerated.During an interview with RNA O on 3/13/2026 at 8:49 a.m., RNA O confirmed Resident 13 was on RNA program for his right knee splinting. RNA O stated they applied Resident 13's right knee splint at 9:00 a.m. and removed at 3:00 p.m.During a concurrent interview with the director of rehabilitation (DOR) and record review of Resident 13's list of care plans on 3/13/2026 at 9:55 a.m., the DOR confirmed there was no care plan developed for Resident 13's RNA program.During a concurrent interview with the MDSC and record review of Resident 13's list of care plans on 3/13/2026 at 1:41 p.m., the MDSC confirmed there was no care plan developed for Resident 13's RNA program. MDSC stated there should have been a care plan developed for Resident 13's RNA program for knee splinting.During a review of the facility's undated policy and procedure titled, Care Plans, Comprehensive Person-Centered, indicated, The comprehensive, person-centered care plan:.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.The interdisciplinary team reviews and updates the care plan:.at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview, and record review, the facility failed to provide services according to professional standards for one of 30 sampled residents (Resident 15) when the speech language pathology (SLP) evaluation and treatment order was not carried out.This failure had the potential to affect Resident 15's care, health, and well-being.Findings:Review of Resident 15's clinical record titled, admission Record, indicated Resident 15 was admitted to the facility with diagnoses including Parkinsonism (a clinical syndrome characterized by a group of movement disorders, primarily featuring tremors, bradykinesia [slowness], muscle rigidity, and postural instability [balance issues]), and chronic pulmonary edema (a long-term condition where fluid slowly and consistently builds up in the lungs' air sac, which causes shortness of breath, fatigue, waking up breathless, and swollen legs).Review of Resident 15's clinical record titled, Order Summary Report, dated 6/30/2025, it indicated the following orders: Mechanical Soft Chopped texture, Thickened Liquid Nectar consistency, Resident on Hospice for Dysphagia [difficulty in swallowing], order dated 6/10/2025. admitted to .Hospice - Admitting Dx [diagnosis] Parkinsonism, unspecified., order dated 6/9/2025. SLP Evaluation and Treatment, order dated 6/11/2025.Review of Resident 15's clinical record titled, IDT [interdisciplinary team - a group of health care professionals from diverse fields who work toward a common goal for residents) Conference Notes, dated 6/17/2025, indicated in therapy services, No Therapy.Resident on hospice.During a concurrent interview with the assistant director of nursing C (ADON C), and record review of Resident 15's 6/17/2025 IDT Conference notes on 3/12/2026 at 9:37 a.m., ADON stated the IDT should review the physician's orders, medications, treatments, if with wounds, and physician orders for life-sustaining treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives). The ADON C stated she was not sure why the SLP evaluation was not completed.During an interview with the director of rehabilitation (DOR) on 3/12/2026 at 10:13 a.m., the DOR stated she ran a report this month (March 2026) and found out the SLP evaluation order in June 2026 was missed.Review of Resident 15's DOR note dated 3/8/2026, indicated, SLP eval [evaluation] and treat order was Missed for 6/11/2025.During a concurrent interview with registered dietitian (RD) and record review of Resident 15's 6/10/2025 RD Weights Note on 3/12/2026 at 12:30 p.m., RD confirmed she recommended the SLP evaluation because of the downgrade in Resident 15's diet. RD stated she did not follow up if her recommendation was completed.During a review of the facility's policy and procedure titled, Speech Therapy, date revised May 2013, indicated, The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders.Speech and Language Evaluation The speech therapist completes an evaluation of the following speech and language skills:.Ability to swallow.

Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Residents 40) were free from unnecessary medication when Resident 40 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) for edema not indicating the specific site of edema and there were no monitoring for the nursing staff to monitor the edema. This deficient practice resulted in unmonitored medical condition.Finding:During a review of Resident 40's clinical record indicated Resident 40 was admitted to the facility on [DATE] with diagnosis including extended spectrum beta lactamase (ESBL, are enzymes produced by certain Gram-negative bacteria that make them resistant to many common antibiotics, including penicillins and cephalosporins) resistance and sepsis (is the body's extreme response to an infection. It is a life-threatening medical emergency.), unspecified. A review of Resident 40's physician's orders indicated an order for Lasix 40 milligram (mg, unit of measure), 1 tablet by mouth one time a day for edema HOLD if (systolic blood pressure) SBP < (is less than) 100, dated 2/6/26. A review of Resident 40's medication administration record (MAR) indicated the nursing staff did not monitor the edema. During a concurrent interview and record review on 3/12/26 at 2:45 p.m., with the Director of Nursing (DON), the DON was asked how they monitor the edema, the DON stated depending on the site of edema, the DON reviewed Resident 40's physician's order for Lasix 40mg for edema and for monitoring of edema, the DON confirmed Resident 40's Lasix the indication for edema, and there were no specific site of edema, the DON confirmed there was no monitoring for edema, the DON further stated Resident 40's Lasix it could be a maintenance medication. During a review of the facility's policy and procedures titled, Medication Therapy, undated, it indicated, Policy Statement 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2.Medication use shall be consistent with an individual's condition .and responses to such treatment.3. All medication orders will be supported by appropriate care and practices . Policy Interpretation and Implementation.2. All decisions related to medications shall include appropriate elements of the care process, such as: a. adequately detailed assessment.5. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: a. when medications is being given in excessive doses, fore excessive period of time, without adequate monitoring, or in the absence of a valid clinical rationale.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and maintenance of one out of two medication refrigerators, when1. A thermometer was not present inside the medication refrigerator, and the internal light did not function when the refrigerator door was opened; and,2. Resident 90's medication was not removed from active stock in the medication refrigerator for nine days after the resident expired.These deficient practices had the potential to result in residents receiving medications with reduced potency, as well as medication errors due to failure to remove discontinued medications from active stock. Findings:1.A review of the medication refrigerator temperature log for [DATE] indicated that, on [DATE], the recorded temperature was 39 F (Fahrenheit).During a concurrent observation and interview with the Assistant Director of Nursing (ADON) C in the medication room on [DATE] at 9:18 a.m., it was observed that there was no thermometer inside the medication refrigerator, and the internal light did not turn on when the refrigerator door was opened. The ADON C confirmed these observations. She stated that the light should function when the refrigerator is opened and that a thermometer should be kept inside the refrigerator to monitor temperature.During an interview with Nurse Supervisor (NS) R on [DATE] at 11:17 a.m., NS R stated that she had checked the thermometer inside the medication refrigerator and recorded a temperature of 39 F on the temperature log. She further stated that she did not know why the thermometer was no longer inside the refrigerator after she checked it. NS R confirmed that the thermometer should be kept inside the refrigerator and that the internal light should be functioning.A review of facility's Refrigerator Temperature log of [DATE] indicates that . record temperature twice daily during AM shift (0700-1530) and PM shift(1500-2330).if the temperature is too warm or too cold (above 41 deg F or below 36 deg F) write the temperature in the space provide and take action.A review of the facility's policies and procedures titled Refrigerators and Freezers dated 2001 indicates that . this facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation.Refrigerator and /or Freezers are maintained in good working condition.2. A review of Resident 90's clinical record indicated that the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a diffuse disease of the brain that alters brain function or structure). Further review of a nursing note dated [DATE] at 3:09 a.m. indicated that Resident 90 expired at 0300 on [DATE].A review of Resident 90's physician order dated [DATE] indicated Metoclopramide (a prescription medication used to treat gastroesophageal reflux disease [GERD] and gastroparesis, or delayed stomach emptying) oral solution 5 mg/5 mL, with instructions to administer 5 mL via G-tube every 8 hours for GERD, starting on [DATE].During a medication refrigerator inspection with the Assistant Director of Nursing (ADON) C on [DATE] at 9:41 a.m., a bottle of Metoclopramide oral solution 5 mg/5 mL labeled for Resident 90 was found inside the medication refrigerator. The ADON C confirmed the observation and stated that Resident 90 had already expired and that the medication should have been removed from the refrigerator.A review of the facility's policies and procedures titled Medication Labeling and Storage, dated 2001, indicates that .if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review the facility failed to ensure supervision was provided for one of three residents (Resident 1) when Resident 1 was left in the hallway unattended.This failure resulted to Resident 1 falling from her wheelchair. Resident1 sustained abrasion in the left elbow.Findings:Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE], with diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), type II diabetes mellitus (high levels of sugar in the blood), muscle wasting (the loss of muscle tissue, strength, and mass) and atrophy (the partial or complete wasting away of a body part or tissue).During an interview with the Occupational Therapist (OT), on 11/25/25 at 1:35 p.m., the OT stated Resident 1 was placed outside the room after therapy. The OT also stated he informed a nurse and a Certified Nursing Assistant (CNA) that Resident 1 was in the hallway. The OT further stated that he does not remember if the nurse and CNA acknowledged when he said the resident was in the hallway.During an interview with the Director of Nursing (DON), on 11/25/25 at 2:05 p.m., the DON stated the resident who witnessed the incident was the resident who caused Resident 1 to fall. The resident was discharged and unavailable for interview. The DON also stated the resident saw Resident 1's wheelchair tipped to the side. The DON stated the resident's backpack that was hanging at the back of the wheelchair got caught to Resident 1's wheelchair. During an interview with Licensed Vocational Nurse (LVN) A, on 12/4/25 at 10:03 a.m., LVN A stated she was across the hallway when the OT placed Resident 1 in the hallway in front of the room. LVN A also stated she acknowledged when the OT told her Resident 1 was back and dropped off Resident 1 in the hallway. LVN A further stated Resident 1 was left in the hallway for about 2 minutes. LVN A stated she turned her back to Resident 1 who was in the hallway to speak to another resident in another room.During an interview with CNA B, on 12/4/25 at 10:18 a.m., CNA B stated she was in another resident's room when she heard a sound like something hit the floor and went out to check. CNA B saw Resident 1 was on the floor on her side facing away from the wheelchair. CNA B also stated the wheelchair was on its side. CNA B resigned from the facility on 1/12/26.Review of Resident 1's Nurse's Note, dated 11/12/25, indicated Resident 1 came back from Good Samaritan Hospital, noted with abrasion to left elbow.Review of Interdisciplinary team (IDT, a group of healthcare professionals from different fields that work together towards a common goal for a patient) note, dated 11/14/25, indicated therapy had just completed a session with Resident 1 approximately 3 minutes before the incident and left Resident 1 in the hallway. Therapist endorsed to nurse who was doing med pass at that time.Review of the facility's policy and procedure, titled Resident Rights, undated, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .

Based on interview and record reviews, the facility failed to provide the necessary care and services for two of 3 sampled residents (Residents 1 and 2) when: 1.Facility staff did not ensure timely assessment, physician notification, or complete documentation of a change in condition for Resident 1; and 2. Facility staff did not notify the physician or conduct a thorough investigation after Resident 2 fell on 2/27/25. These failures placed Residents 1 and 2 at risk for delayed treatment and potential harm. Findings: 1. A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease (partial or complete paralysis on one side of the body after a stroke or brain injury), traumatic hemorrhage of cerebrum (bleeding in the brain caused by trauma), type 2 DM (diabetes mellitus, a chronic condition that affects how the body processes blood sugar), memory deficit following cerebral infarction (memory problems after a stroke). A review of Resident 1's transfer form, dated 2/17/25 at 6:45 p.m., indicated Resident 1 was transferred to the hospital due to malaise (a general feeling of being unwell or weak). A review of Resident 1's progress note, completed by the evening (PM) shift Licensed Vocational Nurse (LVN) A on 2/17/25 at 11:23 p.m., indicated that Resident 1's wife transported him to the hospital after he stated he was not feeling well. LVN A documented that Resident 1's vital signs at the time were within normal limits: blood pressure (BP, the force of blood pushing against the walls of the arteries) 152/89, pulse 76, respiration 18 (process of breathing), and oxygen saturation 97% (O2 sat, the percentage of oxygen in the blood). The progress notes further stated that Resident 1 was taken by his wife at 6:15 p.m., and that at 10:30 p.m., the wife reported Resident 1 had been admitted to the hospital for sepsis (life-threathening condition that could arise due to body's reaction to an infection), as he had been in the past. LVN A documented that the AM (morning) supervisor was notified, and the NOC (night) shift nurse was informed that the resident was in the hospital. A review of the eINTERACT Change of Condition (COC) form, completed by the NOC shift nurse on 2/18/25 at 12:26 a.m., indicated that Resident 1's change in condition began in the afternoon of 2/17/25. The form stated that the resident was complaining of malaise, had vital signs within normal range, and no shortness of breath (SOB) or complaints of pain. The form also documented that Resident 1's blood glucose (BG, the level of sugar in the blood) on 2/17/25 at 4:20 p.m. was 328 mg/dL (milligrams per deciliter, unit of measurement). According to the COC form, the primary care clinician was not notified until 11:38 p.m., several hours after Resident 1 had already been taken to the hospital by his wife. Further review of Resident 1's clinical records, no other documentation indicating what ocurred prior or during the time when Resident 1 left the facility at 6:15 p.m. During an interview on 2/25/25 at 3:30 p.m., with the Certified Nursing Assistant (CNA) B assigned to Resident 1 on the evening of 2/17/25, CNA B stated the charge nurse told her Resident 1 was not feeling well and asked her to take his vital signs. CNA B stated the vital signs were within normal limits. Resident 1 told CNA B he was feeling tired. During an interview with the Director of Nursing (DON) on 2/25/25 at 4:15 p.m., the DON stated that when a resident or family requests a hospital transfer, staff should assess the resident, notify the physician of the assessments, and the family's request, and may facilitate the transfer per family's request, even if vitals signs appear stable. During an interview with the Nurse Supervisor (NS) C on 4/29/25 at 4 p.m., NS C stated she was not aware of Resident 1's complaint or the family's request for transfer until after Resident 1 had left the facility. The NS C confirmed that no timely assessment or documentation occurred during the PM shift, and that the facility protocol requires nurses to assess the resident, document changes, notify the physician, and respond to family requests appropriately. A review of Resident 1's hospital Discharge summary, dated [DATE], stated the resident was admitted on [DATE] for suspected sepsis related to a complicated urinary tract infection (UTI, bladder infection). The summary also noted that the resident had fever, chills, shaking, and malaise for several days prior to admission. The hospital suspected that a viral upper respiratory infection (URI, viral or bacterial illness in the upper airways, including the nose, sinuses and throat) triggered sepsis. Review of the undated facility's policy titled Change in a Resident's Condition or Status indicated, .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, Recommendation) Communication form . 2a.A review of Resident 2's clinical record indicated the resident was admitted on [DATE] with diagnoses including Disseminated Coccidioidomycosis (a serious fungal infection that spread throughout the body); Unspecified injury of Thoracic Spinal Cord (an unclear injury to the part of the spinal cord located in the upper and middle back). A review of the COC form, dated 2/27/25, indicated NO under physician notification, and the explanation field was marked N/A. A review of Resident 2's Progress notes showed no documentation that the physician had been notified following the fall on 2/27/25. During a phone interview with Registered Nurse (RN) D on 5/1/25 at 4:32 p.m., night shift RN D stated that Certified Nursing Assistant (CNA) E reported Resident 2 had fallen during activity of daily living care around midnight. RN D confirmed that he did not notify the physician and did not report to the morning shift nurse about not calling the physician. RN D acknowledged that he should have notified the physician about Resident 2's fall or endorsed it to the morning shift. During a concurrent interview and record review with the DON on 5/20/25 at 4:35 p.m., the DON confirmed that the physician was not notified. The DON stated that the best practice was to notify the physician and document fall monitoring in the progress notes. 2b. A review of the Interdisciplinary team (IDT, a group of healthcare staff from different areas who work together to plan and provide care for a resident) note indicated the IDT note was created on 3/11/25 - 11 days after the effective date of 2/28/25. During a phone interview with CNA E on 5/20/25 at 8:23 a.m., CNA E stated he was assisting Resident 2's roommate at the time of the fall and did not witness the incident. CNA E reported hearing a loud noise and then found Resident 2 on the floor. During a concurrent interview and record review of the IDT note with the Assistant Director of Nursing (ADON) on 5/20/25, at 4:45 p.m., the ADON stated she conducted the fall investigation by interviewing Resident 2 and RN D but did not interview CNA E due to scheduling issues. ADON acknowledged that CNA E's statement contradicted the IDT note, which stated the fall occurred during activity of daily living care with CNA E present. Review of the undated facility's policy titled Change in a Resident's Condition or Status indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition .a. accident or incident involving the resident .d. significant change in the resident's physical/emotional mental condition .g. need to transfer the resident to a hospital/treatment center Review of the undated facility's policy titled Accidents and Incidents - Investigating and Reporting indicated, All accidents or incidents involving residents, employess, visitors, vendors, etc., ocurring on our premises shall be investigated .c. the circumstances surrounding the accident or incident m. other pertinent data as necessary or required

Based on interview and record review, the facility failed to provide services in accordance with professional standards of practice for one of two sampled residents (Resident 1) when license nurses did not accurately complete Resident 1's elopement and wandering risk assessment. This failure had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development), chromosomal abnormality (a genetic condition that occurs when there are missing, extra, or irregular portions of chromosomal DNA [a molecule that carried genetic instructions for the development and functioning of all living organisms]), other lack of expected normal physiological development in childhood (known as developmental delay, means a child or adult is not achieving the expected developmental milestones at the typical age). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/21/25, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 3 (severe cognitive impairment). Review of Resident 1's health status note, dated 1/28/25 at 00:23 a.m., indicated the resident eloped from the facility during shift change, and the resident attempted to leave the facility to go home. Review of Resident 1's elopement and wandering risk observation/assessment, dated 11/9/24, indicated: 0. None present was marked for C. Disease diagnosis: does the resident have a diagnosis that may impact cognition? (i.e., Alzheimer's disease, Anxiety disorder, Bipolar disorder, Delusions, Dementia, Depression, ID/DD, OBS, Schizophrenia, or other not listed); H. Other relevant information was blank; I. Interventions: 1. Has the care plan been initiated/updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement? was blank. Review of Resident 1's care plans indicated there was no care plan developed for elopement or wandering. During an interview and record review with assistant director of nursing (ADON) A on 4/7/25 at 9:10 a.m., she confirmed the record review. ADON A stated Resident 1's elopement and wandering risk observation/assessment, dated 11/9/24 was not accurate for the resident's diagnoses. ADON A acknowledged that 4. Two or more are present should have been marked for question C, and all sections should have been completed. During an interview and record review with licensed vocational nurse (LVN) B on 4/7/25 at 3:45 p.m., she confirmed she completed Resident 1's elopement assessment dated [DATE]. LVN B stated Resident 1's elopement and wandering risk observation/assessment, dated 11/9/24 was not accurate for the resident's diagnoses. LVN B acknowledged that 4. Two or more are present should have been marked for question C, and all sections should have been completed. Review of the facility's undated policy and procedure titled Wandering and Elopements indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated 2001, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure a safe smoking environment and provide supervision for nine of nine residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) who smoked outside of the facility as evidenced by: 1.The facility failed to follow the Minimum Data Set (MDS, a standardized assessment tool for residents' functional status to help identify health problems and to identify the proper care needed) assessment to provide staff supervision and/or physical assistance for nine of nine residents (Residents 1,2,3,4,5,6,7,8 and 9) when these nine residents left their rooms/units and went outside of the facility to smoke at the old smoking area, located at the corner of the facility near a major street and the facility's parking lot. 2.The facility failed to follow four of eight residents' (Residents 2,3,5, and 8) MDS assessment to provide staff supervision and/or staff physical assist when these four residents left their rooms/units, went outside of the facility to smoke, and traversed (traveled across or through) on the sidewalk to and from the new smoking area, which was in a gated garden with a locked gate near the facility parking lot. The sidewalk was adjacent to the facility parking lot. These failures resulted in Resident 1 crossing the street via an electronic scooter (electric powered mobility scooter for adults) from the old smoking area without staff supervision on [DATE]. Resident 1 was hit by a car in the street. Resident 1 was sent to the hospital and died in the hospital on [DATE]. These failures had potential to likely put the other eight residents (Residents 2, 3, 4, 5, 6, 7, and 9) at risk when crossing the parking lot and/or street and likely to be hit by a car (vehicle) without staff supervision. On [DATE], at 6:54 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Regional Director of Clinical Service (RDCS), Director of Nursing (DON), Administrator In Training (AIT), and the facility's Regional [NAME] President (RVP) was on the phone, due to the facility's failure to provide supervision for four of eight residents (Residents 2, 3,5, 8) who smoked when these four residents went outside of the facility to the new smoking area and when these four residents returned from the smoking area to the facility. The facility failed to follow these four residents' MDS assessment requirements regarding the locomotion off unit as three of these four residents (Residents 3,5 and 8) required supervision with one person assist, and one of these four residents (Resident 2) required limited assistant with one-person physical assist. The route to and from the smoking area requires residents to traverse (travel across or through) the sidewalk, which was adjacent to the busy parking lot. On [DATE], at 2:45 p.m., the facility's RDCS submitted an acceptable IJ removal Plan (IJRP, a plan with interventions to immediately correct the deficient practices). On [DATE], at 5 p.m., at the facility, the IJ was lifted. The acceptable IJRP included the following corrective actions: 1) The facility will provide supervision to the four residents and all other residents who smoke when they go outside of the facility to the smoking area and when they return from the smoking area to the facility. Supervision will be done through direct supervision or assistance by the direct care staff/employees or trained staff, and/or through continuous utilization of currently installed facility outer cameras that provide direct line of sight to the ADA (American Disability Act) compliant sidewalk that residents use to propel to and from the smoking area to ensure safety. The outer cameras will be made accessible to the receptionist, licensed nurses at the nursing stations, Administrator, Director of Nursing (DON), and other designees. The facility will designate direct care staff/employees or trained staff to provide supervision and/or assistance for those residents. The facility will continue to utilize the smoking schedule for the residents at the designated smoking area. 2) All residents that go out of the facility who smoke have the potential to be affected by this practice. The interdisciplinary leadership team will monitor that the corrective plan is implemented consistently. 3) The Director of Nursing (DON), Asst. ADON, or Director of Staff Development (DSD) will in-service the direct care staff on providing supervision to all residents who smoke when they go outside of the facility to the smoking area and when they return from the smoking area to the facility. Supervision can be done through direct supervision or assistance by the staff and/or continuous utilization of currently installed facility outer cameras that provide direct line of sight to the sidewalk that residents use to propel to and from the smoking area to ensure safety. 4) The interdisciplinary team (IDT, a group of healthcare professionals from different fields that work together towards common goal for a patient) will conduct a weekly review of staff compliance on following the plan of correction on ensuring residents' safety in the weekly IDT meetings. Any concerns will be discussed by the Administrator or designee for immediate resolution. The IDT will also review daily in the IDT meeting if there are new residents who smoke that require supervision and/or assistance. The DON or designee will keep an updated list of residents who smoke. 5) The Administrator, Director of Nursing (DON) or designee will audit staff compliance in ensuring supervision and safety of residents weekly for 4 weeks, then monthly for 6 months, beginning the week of [DATE], and ending the month of [DATE] and ongoing as needed. Any concerns or issues will be discussed in the daily stand-up meeting for immediate resolution and/or re-assessment by the interdisciplinary team. 6) The Administrator or DON will provide a written quality assurance report that includes evaluation of the effectiveness of the plan of correction in the quarterly Quality Assurance and Performance Improvement meeting for 6 months using pertinent compliance audit information and resolutions from [DATE] through the end of [DATE] and ongoing as needed. 7) The corrective actions began on [DATE], and will be completed by [DATE]. As stated, these failures resulted in Resident 1 being hit by a car in the street and dying in the hospital on [DATE] and had the potential to likely put other eight residents (Resident 2, 3, 4, 5, 6, 7, and 9) at risk to cross the parking lot and/or street and likely to be hit by a car (vehicle) without staff supervision. Furthermore, these failures had potential to put the other residents in the facility at risk when the residents who smoked did not return the cigarettes and lighter to the staff after the smoking. Findings: 1a. Review of Resident 1's Order Summary Report indicated he was admitted to the facility on [DATE], with diagnoses including right ankle and foot acute osteomyelitis (an infection in the bone) and alcohol abuse. Review of Resident 1's acute hospital Admission/Discharge Information signed on [DATE], indicated, he had a right below the knee amputation (BKA). Review of the facility's unusual occurrence report received by the Department on [DATE], indicated that on [DATE], Resident 1 went outside the facility to smoke and decided to take his motorized scooter across the street. The report further indicated Resident 1 was struck by a car. Review of the police report dated [DATE], indicated that Resident 1 was crossing the street at 1990 Fruitdale Ave. with his motorized wheelchair headed north towards the north sidewalk of Fruitdale Ave. Review of Resident 1's acute hospital records dated [DATE] indicated, [years old] man was in a wheelchair in the street and was involved in a collision with a vehicle throwing him 10' (10 feet) from the wheelchair. Bystanders witnessed the event and provided Good Samaritan aid to the patient with rapid CPR [cardiopulmonary resuscitation]. Further review of Resident 1's acute hospital record dated [DATE] indicated, Resident 1 sustained 3 centimeters (cm, unit of measurement) posterior scalp laceration (an injury at the back of the head involving skin tear) with underlying skull fracture (fracture in the head) and laceration to forehead (skin tear in the front of the head). Resident 1's time of death was 11:13 a.m. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated he needed supervision with one-person physical assist for locomotion off unit (how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities, or treatments). If facility has one floor, how resident moves to and from distant areas on the floor. If in a wheelchair, self-sufficiency once in a chair. Review of Resident 1's MDS dated [DATE], indicated he had Brief Interview for Mental Status score of 14 (score of 13 to 15 indicates intact cognition [able to follow commands]). His MDS indicated current use of tobacco was answered no. Review of Resident 1's Physical Therapy PT Evaluation & Plan of Treatment dated [DATE], indicated Resident 1's long term goal # 3 was, Patient will increase ability to safely propel self in wheelchair 200 feet with independence for grasp/release of items, for safe maneuvering in small spaces and for safety awareness. (Target: [DATE]). Review of Resident 1's Physical Therapy PT Discharge Summary electronically signed on [DATE] indicated, Resident 1's long term goal # 3 was discontinued. The record indicated Resident 1's physical therapy was discontinued on [DATE]. The comments indicated wheelchair mobility distance 50 feet with supervision or touching assistance. The comment section of the Physical Therapy PT Discharge Summary indicated Barriers include S/P [status post] amputation on R LE [right lower extremity] amputation on L LE [left lower extremity], NWB [non weight bearing] L LE, .decreased cardiopulmonary [heart and lungs] tolerance, and decreased safety. During an interview with Certified Nursing Assistant A (CNA A) on [DATE], at 2:40 p.m., CNA A stated on [DATE], she saw Resident 1 outside the facility after breakfast. CNA A stated there were no staff that went with the residents when they went to smoke that day. CNA A further stated she had not observed any staff supervising residents who smoke. CNA A verified Resident 1 had a right BKA and needed a one person assist. CNA A stated Resident 1 had used a motorized scooter and a regular wheelchair. CNA A further stated on [DATE], she saw three nurses running from the charting room towards the main entrance of the facility and did not know what was going-on at that time. When asked if there was protective equipment for residents who smoke, like a smoking apron, CNA A stated she did not know what a smoking apron was. During an interview with Licensed Vocational Nurse H on [DATE], at 2:54 p.m., LVN H stated Resident 1 went to the smoking area about 45 minutes to an hour after breakfast. LVN H stated license nurses had direct visual and were able to talk to residents who smoke outside. LVN H further stated they were allowed to visualize the residents who smoke through the charting room and nurses were able to talk to the residents through the sliding door. LVN H stated she checked Resident 1 every 5 minutes or so. When asked what was the time window for the medication pass, LVN H stated typically on the floor at 9 a.m. and finishing medication pass during the incident. LVN H stated she did not see Resident 1 go into the street. LVN H stated Resident 1 was assessed to use the motorized scooter. During a telephone interview with the Physical Therapy (PT) on [DATE], at 12:43 p.m., he reviewed Resident 1's daily notes and stated Resident 1 had right BKA and non-weight bearing on left lower extremity. The PT explained, supervision means a person needs to be near the resident for safety. The PT further explained when a goal was discontinued it means the goal was not met. During a telephone interview with the Minimum Data Set Nurse (MDSN) on [DATE] at 3:22 p.m., the MDSN stated Resident 1's MDS dated [DATE] indicated Resident 1's functional status for locomotion off unit was supervision with one person assist. The MDSN stated supervision means oversight and cueing. The MDSN explained that based on the assessment, Resident 1 needed staff supervision. The MDSN further stated Resident 1 had one side lower extremity impairment with mobility devices such as a walker and wheelchair. During an interview with the regional director of clinical services (RDCS) on [DATE] at 1:34 p.m., the RDCS stated Resident 1's used of motorized scooter was not formally assessed. During an interview with the Director of Nursing (DON) on [DATE], at 1:26 p.m., the DON stated prior to the incident on [DATE], the facility's smoking area was by the sidewalk by the corner of the building. Residents who smoke will tell the nurse when they go to smoke. The resident does not need to sign in and out when they go out to smoke. The DON further stated the facility was a non-smoking facility. The DON added, there were no reasonable rules given to Resident 1 because there was no admission agreement signed by the resident. The DON stated there should be an admission agreement, and unfortunately it was not signed. Review of the XI. Facility Rules and Grievance Procedure of the CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES indicated You agree to comply with reasonable rules, policies, and procedures that we establish. When you are admitted , we will give you a copy of those rules, and policies, and procedures, including a procedure for you to suggest changes to them. During an interview with the MDSN on [DATE], at 2:55 p.m., the MDSN stated the importance of the admission agreement was for the resident or responsible party to know the facility's policy and the care to be provided. Review of the facility's RESIDENT RESPONSIBILITIES AND RULES OF CONDUCT, indicated .10. Resident may not leave the premises without signing out to their respective nurses' station .11. If the facility is a smoking facility, smoking is permitted only in designated areas. Smoking regulations are posted throughout the facility. Smoking regulations must be followed at all times. Some smoking restriction may apply to individual residents . 1b. Review of Resident 2's face sheet (a document that contains the information of the resident) indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses including hemiplegia (loss of muscle function of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke, damage to the brain tissues due to loss of oxygen) affecting left non-dominant side, muscle wasting and atrophy (decreased in size), anxiety disorder (feelings of worry and fears) and depression (persistent loss of interest in activities). Review of Resident 2's MDS indicated Resident 2's BIMS (brief interview for mental status) score was 9 (score of 8 to 12 indicates cognition was moderately impaired). Resident 2's locomotion off unit (how resident moved to and return from off-unit locations, such as areas set aside for dining, activities, or treatments) required limited assistance with one-person physical assist. Resident 2's MDS indicated Resident 2 required a wheelchair as his mobility device. 1c. Review of Resident 3's Order Summary Report, indicated he was admitted to the facility on [DATE], with diagnoses including acquired absence of left leg below the knee (BKA, below the knee amputation), schizophrenia (severe mental disorder affecting how a person thinks, feel, and behaves). Review of Resident 3's face sheet indicated a family member was his responsible party (RP, a person who is accountable in making decision on behalf of the resident). Review of Resident 3's MDS dated [DATE], indicated he had a BIMS score of 12 and he needed supervision (oversight, encouragement, or cueing) with one-person physical assist for locomotion on unit (how resident moves and returns from his room) and locomotion off unit (how resident moves around outside his room or distant areas). Resident 3 required a wheelchair as his mobility device. 1d. Review of Resident 4's face sheet indicated Resident 4 was readmitted to the facility on [DATE], with diagnoses including anemia (body does not have enough healthy red blood cells), history of falling, and muscle weakness. Review of Resident 4's MDS dated [DATE], indicated Resident 4's BIMS score was 14 (cognitively intact). Resident 4's locomotion off unit required supervision with one-person physical assist. Resident 4 required a wheelchair as his mobility device. 1e. Review of Resident 5's face sheet indicated Resident 5 was admitted to the facility on [DATE], with the diagnoses including difficulty in walking, other specified disorders of the brain, and muscle wasting and atrophy (decreased in size). Review of Resident 5's MDS dated [DATE], indicated Resident 5's BIMS score was 10. Resident 5's locomotion off unit required supervision with setup. Resident 5 required a wheelchair as his mobility device. 1f. Review of Resident 6's face sheet indicated Resident 6 was admitted on [DATE], with diagnoses of difficulty in walking, muscle wasting and atrophy. Review Resident 6's MDS dated [DATE], indicated Resident 6's BIMS score was 15. Resident 6's locomotion off unit required supervision with one-person physical assist. Resident 6 required a wheelchair as his mobility device. 1g. Review of Resident 7's face sheet indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy, muscle weakness, anxiety disorder. Review of Resident 7's MDS dated [DATE], indicated Resident 7's BIMS score was 15. Resident 7's locomotion off unit activity occurred only one or twice with one-person physical assist. Resident 7 required a wheelchair as his mobility device. 1h. Review of Resident 8's face sheet indicated Resident 8 was admitted to the facility on [DATE], with diagnoses of abnormalities of gait and mobility, along with anemia. Review of Resident 8's MDS dated [DATE], indicated Resident 8's BIMS score was 15. Resident 8's locomotion off unit required supervision with one-person physical assist. Resident 8 required a wheelchair as his mobility device. 1i. Review of Resident 9's face sheet indicated Resident 9 was admitted to the facility on [DATE], with diagnoses including abnormal posture, fall, psychoactive substance (a chemical substance that could change the perception or mood) abuse, hemiplegia (loss of muscle function of one side of the body) and hemiparesis (weakness of one side of the body). Review of Resident 9's MDS dated [DATE], indicated Resident 9's BIMS score was 15. Resident 9's locomotion off unit required supervision with one-person physical assist. Resident 9 required a wheelchair as his mobility device. 2. During an observation and interview with the facility Regional [NAME] President (RVP) and the Regional Director of Clinical Service (RDCS) on [DATE], at 3:45 p.m., both RVP and RDCS used a measurement device to measure the distance between the facility main entrance area to the old smoking area and to the new smoking area. The RVP and RDCS stated the distance between the facility main entrance area to the old smoking area was 180 feet. The distance from the main entrance area to the new area smoking area was 80 feet. During an observation at the new smoking area on [DATE], at 11:30 a.m., a locked gate was between the new smoking area and the sidewalk. The sidewalk was adjacent to the facility parking lot. The sidewalk was leading to the facility main entrance. There were six residents sitting in their wheelchairs while smoking in the smoking area. During an interview with CNA D on [DATE], at 11:37 a.m., CNA D stated she was just assigned to watch the residents to smoke in the new smoking area today ([DATE]). CNA D stated there was no staff to supervise residents to smoke at the old smoking area before. CNA D stated she was just told to sit and watch the resident in the new smoking area. She stated she did not get any training regarding how to supervise these residents in the new smoking area in case an emergency occurred. CNA D stated residents came and went freely by themselves, and no staff supervised and accompanied the residents when they wheeled themselves on the sidewalk to and from the new smoking area. During an observation on [DATE], at 11:50 a.m., Resident 3 was observed to wheel himself via a wheelchair to the new smoking area through the sidewalk by himself. No staff accompanied or supervised him at the sidewalk. During an observation on [DATE], at 11:54 a.m., Resident 3 wheeled himself from the new smoking area back to the facility through the sidewalk. No staff accompanied or supervised Resident 3 when Resident 3 left the smoking area and back to the facility. During an observation on [DATE], from 12 p.m. to 12:05 p.m., five cars droved by the sidewalk near the new smoking area. During an observation on [DATE], at 1:30 p.m., Resident 2 wheeled himself via a wheelchair through the sidewalk to the new smoking area. No staff accompanied or supervised Resident 2 when he wheeled himself to the new smoking area through the sidewalk. During an interview with CNA J on [DATE], at 1:43 p.m., he stated he was just assigned to watch the resident to smoke in the new smoking area last Friday or Saturday. CNA J stated most residents came to smoke and went back to the facility by themselves through the sidewalks, and no staff supervised these residents when residents wheeled themselves on the sidewalk to and from the smoking area. During an observation on [DATE], at 1:51 p.m., Resident 3 wheeled himself through the sidewalk from the new smoking area towards the main entrance of the facility. No staff accompanied or supervised him at the sidewalk. Resident 3 wheeled himself back to his room and did not return his cigarette or lighter. When a surveyor interviewed Resident 3 at 1:54 p.m., Resident 3 stated he returned his cigarette and lighter to the nurse already. During an interview with LVN C on [DATE], at 1:56 p.m., LVN C stated she did not know Resident 3 came back to his room from smoking. LVN C stated Resident 3 did not return his cigarette and lighter at this time. LVN C stated Resident 3 should have returned the remaining cigarette and lighter after smoking. LVN C further stated Resident 3 had his last cigarette and may have no cigarette to return, but Resident 3 should have returned his lighter after smoking. During a concurrent observation and interview on [DATE], at 1:59 p.m., LVN C found Resident 3 at the activity room. Resident 3 returned his lighter to LVN C when LVN C asked the resident. LVN C stated Resident 3 sometimes forgot to return his cigarette and lighter after smoking. During an observation on [DATE], at 2:05 p.m., Resident 2, Resident 3, and Resident 7 were sitting in their wheelchairs and smoking in the new smoking area. There were no facility staff in the smoking area to watch Residents 2,3 and 7. CNA J was standing and talking to one resident who was in the wheelchair at the sidewalk near the new smoking area. At 2:10 p.m., CNA J opened the locked gate and entered the new smoking area to watch the residents who smoked. During an interview with CNA J on [DATE], at 2:19 p.m., when CNA J was asked why he was outside of the new smoking area instead of inside the smoking area to watch the residents, CNA J stated that one resident finished smoking and tried to wheel himself by crossing the parking lot to go to a store (resident needed to cross the street to get to the store) to buy something. CNA J stated he had to stop the resident and called a facility supervisor to help handle the situation since he needed to go back to the new smoking area to watch the other residents who smoked there. CNA J stated he did not know the name of the resident who tried to cross the parking lot to go to a store, but this resident always came and left the smoking area by himself unaccompanied or unsupervised by staff on the sidewalk. During an observation and interview with Resident 4 at the new smoking area on [DATE], at 2:13 p.m., Resident 4 finished smoking and sat in the wheelchair. Resident 4 stated he and other residents started to smoke at this new smoking area since last weekend. Resident 4 stated the old smoking area, which was located at the corner of the street and the parking lot was not safe for him and other residents to smoke. Resident 4 further stated there was no staff who watched or supervised them at the old smoking area. During an observation and interview with Resident 7 at the new smoking area on [DATE], at 2:25 p.m., Resident 7 was sitting in a wheelchair and smoking. Resident 7 stated he just came and left the new smoking area through the sidewalk, and no staff provided supervision when he wheeled himself through the sidewalk. During an observation and interview with Resident 2 at the new smoking area on [DATE], at 2:28 p.m., Resident 2 was sitting in a wheelchair and smoking. Resident 2 stated before last Friday ([DATE]) he went outside of the facility to the old smoking area to smoke whenever he wanted without staff supervision at the old smoking area. Resident 2 stated he came and left the new smoking area through the sidewalk without a staff watching or supervising him at the sidewalk. During an observation with Resident 5 at the sidewalk near the new smoking area on [DATE], at 3:30 p.m., Resident 5 wheeled himself via a wheelchair back to the facility from the new smoking area through the sidewalk. There was no staff supervising Resident 5 at the sidewalk. During an interview with Resident 6 on [DATE], at 3:01 p.m., he stated prior to [DATE] there was no smoking area, since the facility is a non-smoking facility. The residents who smoked went out to the sidewalk and, off of the facility's property. After Resident 1's accident last [DATE], the facility provided the garden area at the right rear of the parking lot as the designated smoking area. During an interview with Resident 9 on [DATE], at 9:48 a.m., Resident 9 stated he had the tendency to drop his cigarettes at times and would not notice until he had burned. Resident 9 further stated, he does not tell anyone when he goes out to smoke and that staff members were not present all the time while he smokes. During an observation and subsequent interview with Resident 6 on [DATE], at 10:05 a.m., in the smoking area, Resident 6 had ashes on his shirt and pants. He stated it was not a problem and brushed off the ashes. During an observation on [DATE], at 10:15 a.m., one resident left through the gate, which leads to the parking lot, to go into the building. He had to push on the handle a few times to get it open. He was not accompanied by facility staff. During an interview with Resident 7, 8 and 9 on [DATE], at 11:40 a.m., the residents were sitting in the new designated smoking area, Resident 7, 8 and 9 all stated they all wheeled themselves without staff assistance to and from the smoking area. During an observation on [DATE], at 11:51 a.m., Resident 3 came into the smoking area through the front gate without staff assistance or supervision. During an observation on [DATE], at 11:54 a.m., Resident 8 went inside the facility, from the smoking area without staff assistance or supervision. During an observation on [DATE], at 12:02 p.m., a nurse near a medication cart, spoke briefly to Resident 8 and did not ask Resident 8 to return the cigarette or lighter. During an interview with Licensed Vocational Nurse B (LVN B) on [DATE], at 2:04 p.m., LVN B stated, residents who smoke usually roll themselves to the smoking area and back to the facility. During an interview with Resident 8 on [DATE], at 2:19 p.m., he stated prior to the incident on [DATE], they had been smoking on the sidewalk by the street. After the incident they now go to the garden area. Resident 8 stated he could wheel himself, and that no one helps him going to the smoking area or when he returns to the facility. During an interview with Resident 7 on [DATE], at 2:59 p.m., Resident 7 stated he could wheel himself going to the smoking area and back to the facility. He stated the staff does not assess him for burns after smoking. Review of the facility's policy, Smoking Policy-Residents revised [DATE] indicated, Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Review of the facility's policy, Safety and Supervision of Residents revised [DATE] indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a fall for one of three sampled residents (1) when transferring Resident 1 from the bed to a wheelchair using a mechanical lift. Certified nurse assistant A (CNA A) failed to use a two person assistance, use the lift as per the manufacturer's guidelines, or call for help when she realized the resident was going to fall. As a result of the fall, it indicated Resident 1 had two leg fractures and required blood transfusions resulting from bleeding at the fractured sites. Resident 1 expired 10 days later in the acute care hospital. Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 1's clinical record was done on [DATE]. Resident 1's [DATE] Minimum Data Set (MDS, an assessment tool), indicated Resident 1 was moderately impaired in decision making skills. The MDS also indicated Resident 1 was totally dependent on staff and required a two person physical assist for transfers and bed mobility. It further indicated Resident 1 had a lower extremities impairment that interfered with daily functions or placed the resident at risk of injury during transfer. Licensed vocational nurse B (LN B) nurse's note dated [DATE] at 11:19 a.m. indicated Resident 1 fell on [DATE] at 10:20 a.m. The same note indicated when CNA A stood Resident 1 on the Vera lift (portable lifting machine), the resident started pushing away from the machine. The note indicated the resident had been found in a sitting position on the floor and was assessed to have no swelling, discoloration or skin tears but still had stiffness and contractures both lower legs. After the assessment, the resident was placed in a wheelchair and taken to the patio to smoke. Resident 1's nurse's notes for [DATE] indicated a physician's orders [REDACTED]. The X-ray was taken at 9:30 p.m., and the results were received at 12:45 a.m. on [DATE], which indicated an acute distal (end closest to the knee) femur (thigh bone) fracture (an abnormal, often permanent shortening that results in distortion or deformity with stiffness). During interview on [DATE] at 11:20 a.m., CNA A who witnessed the fall, stated she transferred the resident out of bed without assistance. She stated on the day of the incident Resident 1 wanted to go to the smoking patio. CNA A stated she proceeded with the transfer because the resident was yelling and agitated. She stated she noticed the resident's knees were bent during the transfer. CNA A stated she was concerned the resident might fall because of her posture during transfer. CNA A stated she should have called for assistance. On [DATE] at 2:30 p.m., CNA A demonstrated by using the nursing supervisor (NS) as a stand in for Resident 1, transferred Resident 1 from bed to wheelchair on the day of the fall. The following movements were observed during the demonstration: The resident sat at the edge of the bed, placed her feet on the floor pad and CNA A stated and demonstrated Resident 1 was still moving both feet. CNA A pressed the up and down button and lifted the resident from a sitting to standing position. CNA A demonstrated when Resident 1 got on the machine (lift), her feet were not centered correctly on the foot pad. Both knees and legs were bent and slipped off the knee pad. The resident held the hand grips as the body shifted towards her left side. While in this position, CNA A proceeded to move the resident out from the bed towards the side of the room. CNA A demonstrated she had to use the up and down switch while attempting to keep Resident 1 in position. She then lowered the resident in a lateral squatted position to the floor. NS stated this would increase pressure on the contracted knees and CNA A should have called for help. CNA A called for help after the resident was lowered to the floor. During the transfer, CNA A stood behind the lift holding the up and down remote button. The demonstration showed the distance between the CNA and the resident made it difficult for CNA A to manage the device as well as control the resident's posture. At the time of the fall, there was no one present in the room to help CNA A ensure that the resident's legs were properly positioned. A review of the Vera-Lift resident transfer procedures in he manual for basic standing transfers indicated staff should do the following: 1. Help the resident place his or her feet on the foot pad with the resident's knees against the knee pads. The procedure indicated it was important that the resident's feet be flat on the base of the foot pad. A review of the ,[DATE] Vera-lift manufacturer's manual indicated that residents who are not suitable for Vera-lift standing transfers are residents who have injuries or medical conditions that might be aggravated by the mechanical device. Also contraindicated are residents who exhibit unpredictable behavior that might pose risk of injury to the resident or those residents who are unable to follow simple directions. Resident 1 suffered leg contractures, agitation and yelling during transfer, dementia and was unable to position her feet properly. During interview on [DATE] at 11:34 a.m., licensed nurse B (LN B) stated for safety purposes, two people are normally required when transferring a resident with mechanical device. During interview on the same date at 3:28 p.m., CNA C stated it was safer and easier for two people to move the resident with the mechanical device because the resident had contractures on both knees. She stated Resident 1 is "Okay" holding the bars with her hands but not standing on her legs. During interview on [DATE] at 9:28 a.m., CNA D stated Resident 1 was capable of bending her knees but was not able to stretch her "legs all the way out." She stated the resident's legs should be rested directly against the knee pad for support during transfer with Vera lift. CNA D stated during two-person assist, one person controls the machine while the second assistant ensured the resident is safely positioned on the machine during transfer. On [DATE] at 8:58 a.m., the director of nurses (DON) stated it was the facility's policy to have a two-person assistance when transferring a resident with mechanical device. He stated "Everyone knows the resident was a two person assist." The facility's ,[DATE] policy and procedure, "Using a portable lifting machine," indicated the portable lift can be used by one nursing assistant if the resident was able to participate. However, if the person was not able to participate, a two person assistance would be required. The MDS assessment and the investigative report indicated Resident 1 required a two person assistance when transferring with a mechanical device. The DON acknowledged Resident 1 was suitable for a two person assistance considering her mental status and physical limitation, hence she was not able to fully participate during the transfer A [DATE] discharge summary from the acute care hospital indicated Resident 1 was diagnosed with [REDACTED]. The discharge summary notes from the hospital also indicated Resident 1 died on [DATE]. The note further indicated the cause of Resident 1's death was due to bilateral (both legs) femur fractures, hypercapnia (too much carbon dioxide in the blood) and respiratory failure.

Based on interview and closed record review, the facility failed to provide comprehensive assessments, implement its care plan to notify the physician promptly of any changes, revise the care plan when necessary, and provide timely referral for one of three sampled residents (1). Resident 1's assessment was not completed according to professional standards and the facility's policy and procedures. On [DATE], Resident 1 developed a reddish purple discoloration on the side of the big toe and baby toe on her left foot. Resident 1's nursing care plan for reddish-purplish discoloration was not updated when the wound deteriorated and developed eschar (black discoloration). Resident 1's physician was not notified when she developed pain and fever. The facility documented observations daily but the resident developed an eschar on [DATE] and was not seen by a physician until [DATE] even though the care plan on [DATE] and professional standards indicated more timely interventions were needed. When the resident was finally seen in the wound clinic she was immediately sent to the acute care hospital emergency room in severe pain and diagnosed with [REDACTED]. Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1 had a possible increased risk of developing wet and dry gangrene due to her history of diabetes and vascular compromise. The [DATE] minimum data set (MDS, an assessment tool) indicated the resident had occasional pain, no ulcers and was usually understood and understood others. Resident 1 was able to recall two of three items without cues five minutes after being told three words. The [DATE] physician orders [REDACTED]. Closed record review (a medical record for a resident who is no longer in the facility) was conducted on [DATE]. The [DATE] resident progress notes at 9:50 a.m. indicated licensed vocational nurse A (LN A) noted reddish purple discolorations on the sides of the first and fifth toes of the left foot. According to the note, the resident denied pain, she stated she had sensation to her feet when touched, and the physician was notified. However, there was no documentation of the size, temperature, whether the wound was closed or open, or had any drainage, odor or swelling. According to the Medscape article on Assessment and Terminology: Critical Issues on Wound Care accessed at www.medscape.com/viewarticle/ 9, a wound assessment includes measurements taken in millimeters or centimeters, a description of the condition, color and temperature, a pattern or distribution of the lesion, any drainage, and any odor. According to Medscape's article, "The Role of [MEDICAL CONDITION] in the Patheogenesis of Diabetic Foot Disease: When to Refer for Vascular Surgery," any newly occurring ulcer should be referred for assessment by a vascular surgeon within 1 working day The clinician is to contact vascular surgical services by telephone, e-mail, or fax. Ulceration and ischemia of the foot in diabetes is an emergency and should be referred immediately for specialist assessment. Early identification of patients improves outcome. The symptoms and signs of ischemia of the foot in diabetes may be masked because of [MEDICAL CONDITION]. Pain is an unusual symptom and is often an indicator of limb threatening complication (such as infection, abscess, or critical ischemia). It is imperative that family physicians regularly examine the feet of patients with diabetes. Despite specialist assessment and revascularization, the healing of foot ulcers among individuals with poor circulation and diabetes is poor. The [DATE] care plan identifying a problem of reddish-purplish discoloration indicated the resident had a reddish-purplish discoloration on the left side of the first and fifth toes and would have no complications to the affected site for one week. According to the care plan approach the resident was to have a vascular consult and nursing would observe any "worsening con9dition (sic) on the affected site and notify the MD." Licensed vocational nurse D's (LN D) [DATE] nurse's note at 7:05 p.m. indicated it was a late entry for [DATE] at 7:03 p.m. The note indicated there were no signs and symptoms of infection, no increase in size, no swelling and redness. However, there was no documentation of the original size on [DATE] of the discolorations to provide a basis for this comparison. Between [DATE] and [DATE], the only other note regarding Resident 1's first and fifth left toes was found on the ,[DATE] Treatment Flow Sheet (TFS). The TFS indicated "left toes: observe for purplish reddish discoloration for any significant changes" every shift. The TFS had a nurse's initial in each box three times a day between [DATE] and [DATE]. LN G's nurse's note on [DATE] at 10:38 a.m. indicated the resident still had multiple purplish reddish discolorations on the great toe and fifth toe on the left foot. Also, the resident's left lateral (side) great toe was now noted to have eschar (dark dead tissue). The nurse indicated the resident had an appointment with the wound clinic on [DATE]. The [DATE] care plan was not updated to reflect the resident's change in condition. Although the resident's great toe on the left foot now had eschar, nursing decreased the observations on her left toes to once a day. The February 2011 TFS indicated observations beginning [DATE] were done on the day shift only. The TFS indicated observations were done on the day shift of the purplish reddish discoloration on the left toes for any significant changes. Also, observations were done on the day shift of the eschar on the resident's left great toe. Again, there was no assessment indicating the size, odor, drainage and the condition of the wound and adjacent tissue. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation as to the exact location of the pain. According to the facility's policy and procedure, "Pain-Clinical Protocol" dated [DATE] staff will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.). The staff and physician will also evaluate how pain is affecting mood. The physician will help identify causes of pain by examining the resident directly. The nurse's note at 10:02 a.m. on [DATE] indicated Resident 1 missed her appointment at the wound clinic that day, and Resident 1 now had a wound care appointment on [DATE] at 10:45 a.m. Again, on [DATE] at 9 a.m. and 3 p.m., Resident 1's MAR indicated leg pain". Resident 1's [DATE] vital sign record at 7:48 p.m. indicated her temperature had risen to 99.2 degrees Fahrenheit. There was no evidence in the clinical record that nursing assessed the resident's left foot eschar in relationship to her leg pain and a low-grade temperature. The registered nurse wrote a note on [DATE] at 1:45 p.m. and indicated she called the attending physician and notified him, "about the discoloration and eschars on the resident's left toes were noted to be increased in size, pained when touched." The note indicated the physician instructed the facility to wait until the resident's appointment on [DATE]. The nurse's note did not indicate the physician was notified the resident had leg pain and fever on [DATE]. The facility's policy and procedure dated [DATE], "Pressure Ulcers/Skin Breakdown/Benign Skin Conditions-Clinical Protocol" indicated the nurse "shall assess and document/report the following: vital signs, full assessment of pressure sore including location, stage, length, width...presence of necrotic tissue...pain assessment." According to the facility's policy and procedure dated [DATE], "Resident Event/Condition Changes-Clinical Protocol" before contacting a physician about an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician including the resident's current symptoms and status including vital signs. The physician should ask questions to clarify the situation; for example, vital signs. Record review was again conducted on [DATE]. The [DATE] wound clinic document indicated the staff documented Resident 1 presented to the clinic "with gangrene (<http://www.medicinenet.com/gangrene/article.htm> titled "Gangrene," gangrene is a term that describes dead or dying tissue that occur because of a loss of blood supply to the tissue) of the left foot wounds ...marked odor, erythemic (red) streaking up the foot." The resident was sent directly to the acute care hospital emergency room . The [DATE] physician's exam indicated Resident 1 was in quite a bit of distress, with severe pain to the left leg. She had ascending [MEDICAL CONDITION] (infection of the skin and subcutaneous tissue) up the middle of the left leg and also streaking (streaking can suggest the condition has become rather serious) following most of the venous structures (veins). The [DATE] wound clinic document indicated "ulcerations are located on the middle of the first joint of the left great toe, the joint of the fifth toe and a heel wound." According to the physician's note, Resident 1 had "ascending [MEDICAL CONDITION] emanating from the area of both wet and dry gangrene." She was sent to the emergency roiagnom on an urgent basis. According to Pages ,[DATE] of the book "Wound, Ostomy, and Continence Nursing Secrets" 2003 wet gangrene usually occurs when dry gangrene becomes infected and can be felt as soft and boggy. The facility's policy and procedure, "Nursing Care of the Resident with Diabetes Mellitus" dated [DATE] indicated caring for the diabetic resident includes carefully assessing the resident's feet for "hygiene, temperature, color, circulation, any abrasions, sore and or injuries. . . ." During an interview and record review on [DATE] at 11:46 a.m., registered nurse A (RN A) stated Resident 1's "left side of the first and fifth toes" on the left foot was bruised and the left side of the first toe developed an eschar one week after the bruises were discovered. RN A stated nurses only documented for three days after the bruising was noted. RN A stated the facility did not document their observation on any skin sheets. During a confidential staff interview on [DATE] at 1:41 p.m., a staff member stated Resident 1's room had the odor of a "dead rotting animal" from [DATE] through [DATE]. The staff stated the licensed nurses were told about the odor and replied that all diabetic resident's wounds smelled bad. During an interview and record review on [DATE] at 11:50 a.m., licensed vocational nurse G (LN G) stated she signed Resident 1's treatment record for the day shift from [DATE] through [DATE] except for four days. LN G stated the side of Resident 1's big toe and fifth toes were reddish. LN G stated the facility did not do "skin sheets" indicating the size of the discoloration. During an interview on [DATE] at 10 a.m., the resident's responsible party stated he saw the resident at the wound clinic on [DATE]. Resident 1's left heel skin was missing and looked raw. The RP also stated the foot had a rotten odor. The skin between the toes was black and it was not dirt. The facility failed to conduct an assessment according to the facility's policy for diabetic foot care and professional standards. The facility failed to modify their care plan when the anticipated outcome was not achieved and eschar developed. The facility failed to notify the physician of Resident 1's complaint of leg pain and fever. The facility failed to arrange timely consultation by a specialist according to professional standards. Resident 1 had a history of [REDACTED]. Resident 1 developed reddish purple discolorations on the side of her left big toe and baby toe on [DATE]. No physician evaluated her between [DATE] and [DATE]. Despite the facility observing the foot daily, no physician saw Resident 1 until she was seen in the wound clinic on [DATE]. She was diagnosed with [REDACTED]. The wound clinic sent the resident directly to the acute care hospital for treatment. A [DATE] acute care hospital discharge summary indicated on [DATE] Resident 1's "gangrene appeared to be very severe and for that reason, she was admitted for further surgical evaluation and possible left below-knee amputation." She was to be evaluated for a left lower leg amputation, but she became more septic (severe bacterial infection). She was treated in the intensive care unit where her condition deteriorated and she became more unresponsive. Resident 1 expired on [DATE].